PERKINS  LIBRARY 

Duke    University 


Kare  Dooks 


\r&-0-^W 


I 


THE 


PRINCIPLES 


OP 


IllWIfllll 


INCLUDING  THE 


DISEASES  OF  WOMEN  AND  CHILDREN. 


BY  JOHN  BURNS,  C.  M. 

REOICS  PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITT  OF  GLASGOW, 
&C.  &C. 


FROM  THE  FIFTH  LONDON  EDITION,  ENLARGED,  WITH  AP- 
PROVEMENTS AND  NOTES,  BY 

T.  C.  JAMES,  M.  D. 

PROFESSOR  OF  MIDWIFERY  IN  THE  UNIVERSITT  OF  PENNSYLVANIA. 

IN  TWO  VOLUMES. 
^  VOL.  I. 

V 

PHILADELPHIA : 

PUBLISHED  BY  EDWARD  PARKER,  No.  178,  MARKET-STREE T. 
J.  H.  Cunningham,  printer. 

1823. 


Eastern  District  of  Pennsylvania,  to  wit : 

II      BE  IT  REMEMBERED,  That  on  the  fourth  day   of  February, 
|  SEAL.  I     in  the  forty-seventh  year  of  the  Independence  of  the  United  State9 
»   of  America,  A.  D.  1823,  EDWARD  PARKER,  of  the  said  district, 


hath  deposited  in  this  office  the  title  of  a  book,  the  right  whereof  he  claims  as 
proprietor,  in  the  words  following,  to  wit : 

•:  The  Principles  of  Midwifery  ,•  by  John  Burns,  C.  M.  Regius  Professor  of  Sur*- 
gery  in  the  University  of  Glasgow,  &c.  &c.  From  the  fifth  London  Edition,  en- 
larged,  -with  improvements  and  notes,  by  T.  C.  James,  M~.  U.  Professor  of  Mid- 
wifery, in  the  University  of  Pennsylvania." 

In  conformity  to  the  act  of  the  Congress  of  the  United  States,  entitled  **  An 
Act  for  the  encouragement  of  learning,  by  securing  the  copies  of  maps,  charts, 
and  books,  to  the  authors  and  proprietors  of  such  copies,  during  the  times 
therein  mentioned" — And  also  to  the  Act,  entitled  "  An  Act  supplementary  to 
An  Act,  entitled  "  An  Act  for  the  encouragement  of  learning,  by  securing  the 
copies  of  maps,  charts,  and  books,  to  the  authors  and  proprietors  of  such  co- 
pies during  the  times  therein  mentioned,"  and  extending  the  benefits  thereof 
to  the  arts  of  designing,  engraving,  and  etching  historical  and  other  prints." 

D.  CALDWELL, 

Clerk  of  thte  Eastern  District  of  Pennsylvania. 


- 


THE  AUTHOR'S  PREFACE. 


IN  preparing  this  work,  I  have  endeavoured  to  proceed  as 
much  as  possible  upon  the  method  of  induction.  I  have  collected 
with  care  the  different  cases  which  have  been  made  public,  as 
well  as  my  own  private  observations.  To  these  I  have  added  the 
opinions  and  advices  given  by  others,  in  so  far  as  they  seemed  to 
be  founded  on  facts,  and  supported  .by  experience.  From  the 
whole  I  have  deduced,  in  the  different  parts  of  my  subject,  both 
the  symptoms  and  the  practice. 

The  anatomical  descriptions  I  have  given  from  dissections  and 
preparations  before  me  whilst  writing. 

I  intended  to  have  added  to  the  text  copious  references  to  the 
opinions  and  cases  contained  in  systems,  or  scattered  through 
other  publications.  This  would  have  rendered  the  present  book, 
in  some  manner,  an  index  to  those  already  published,  and  been  of 
considerable  service  to  practitioners,  who  wished  to  consult  them 
upon  any  particular  point.  But  in  spite  of  all  my  endeavours,  the 
work  has  extended  to  a  length  which  rendered  it  necessary  to 
strike  out  many  references,  and  shorten  the  account  of  cases,  to 
prevent  it  from  swelling  to  a  size  which  would  have  rendered  it 
less  generally  useful. 

Should  this  work  fall  only  into  the  hands  of  those  competent  to 
judge  in  their  profession,  it  would,  if  faulty  or  deficient,  do  little 


IV 

harm :  But  as  it  has  been  circulated  extensively,  it  must,  like 
other  systems  and  elements,  have  an  influence  on  the  opinions 
and  future  practice  of  the  student  of  midwifery ;  and  will  prove 
useful  or  injurious  to  society,  according  to  the  correctness  of  the 
principles  it  contains.  When  I  consider  how  important  the  dis- 
eases of  women  and  children  are,  and  how  much  depends  on  the 
prudent  management  of  parturition,  I  feel  the  high  responsibility 
which  falls  on  those  who  presume  to  give  lessons  in  midwifery. 
I  do,  however,  sincerely  trust,  that  the  precepts  1  have  inculcated 
will  be  found  agreeable  to  experience ; — and,  on  a  review  of  the 
whole,  I  cannot  say  that  I  have  either  wasted  the  reader's  time  in 
idle  theory,  or  misled  his  opinion  by  mere  speculation. 

In  preparing  a  fifth  edition  for  the  press,  I  have  carefully  re- 
vised the  whole  work,  and  have  made  additions,  exceeding  a  hun- 
dred pages. 

The  notes  which  were  formerly  thrown  to  the  end  of  the  book, 
f  have  now  placed,  for  the  convenience  of  the  reader,  at  the  foot 
of  the  pages  to  which  they  belong. 

Glasgow,  Sept.  1820. 


ADVERTISEMENT  BY  THE  EDITOR. 


THE  following  highly  flattering  character  of  the  ensuing  work, 
was  given  in  the  Edinburgh  Medical  and  Surgical  Journal,  for  the 
year  1810;  since  which  it  has  passed  through  four  successive  edi- 
tions by  the  author,  each  of  which  has  added  considerably,  not 
simply  to  the  size,  but  also  to  the  intrinsic  value  of  the  work. 

"  The  author,  equally  experienced  as  a  teacher  and  practitioner, 
has  by  a  judicious  arrangement,  by  a  faithful  exposition  of  facts 
and  observations,  and  by  a  methodical  induction  of  the  principles 
and  practice  of  the  art,  accomplished  in  this  work  all  that  could  be 
expected,  in  the  present  state  of  the  science,  to  give  a  new  interest 
to  the  subject.  # 

"  The  prominent  advantage,  that  confers  upon  it  a  decided  pre- 
ference to  all  others,  as  a  System  or  Class-book,  is,  that  every  sub- 
ject, directly  or  indirectly  connected  with  the  practice  of  the  ac- 
coucheur, is  here  brought  into  one  connected  view. 

"  But  what  we  are  most  disposed  to  recommend  in  this  volume, 
is  the  pathological  department,  and  the  descriptions  and  treatment 
of  the  diseases  of  puerperal  women,  and  of  children.  A  more  co- 
pious, scientific,  and  judicious  account  of  these  diseases,  is  perhaps 
no  where  to  be  met  with." 


VI 

One  great  advantage  of  this  work  to  the  student  solicitous  of  full 
and  accurate  information  on  the  subjects  of  which  it  treats,  is  to  be 
experienced  in  the  very  valuable  notes  and  references  of  the  au- 
thor, to  almost  all  that  has  been  communicated  by  practitioners  of 
deserved  celebrity,  on  parallel  subjects  or  cases.  In  this  point  of 
view,  it  may  be  considered  as  the  Common-place  Book  of  an  im- 
mense fund  of  the  most  useful  practical  knowledge,  indispensible  as 
a  guide  to  the  inexperience  of  the  student,  and  earlier  practitioner, 
and  of  no  ordinary  utility  and  aid  to  the  maturer  acquirements  of 
advanced  and  established  professional  skill. 

This  edition  has  been  considerably  enlarged  and  improved  by 
the  author.  The  sections  on  abortion  and  uterine  hemorrhage, 
will  be  found  to  have  been  very  considerably  extended,  and  ren- 
dered of  far  greater  value  ; — indeed,  they  may  now  be  considered, 
as  containing  the  essence  of  his  separate  Treatises  on  those  very 
interesting  subjects,  which  have  for  some  time  enjoyed  the  appro- 
bation of  the  public. 

The  new  articles,  totally  omitted  in  the  former  edition,  but  by 
the  author  introduced  into  this,  are  those  on  pneumonia,  on  ephe- 
meral fever,  on  weed  or  intestinal  fever,  and  on  diarrhoea,  as  existing 
in  the  puerperal  state,  and  on  chorea,  on  bronchitis,  and  on  perito- 
nitis, as  the  diseases  of  the  infantile  age.  These,  it  is  presumed, 
will  not  fail  to  give  additional  interest  to  the  work. 

The  editor  has  taken  the  liberty  of  introducing  into  the  text,  a 
section  on  the  difference  between  the  male  and  female  pelvis ; 
which,  as  he  conceived,  the  autlior  ought  not  to  have  omitted;  and 
Dr.  Clarke's  account  of  the  cauliflower  excrescence  of  the  os  uteri. 


Vll 

Whether  this  is  only  a  variety  of  the  spongoid  tumour,  he  will  leave 
to  the  reader  to  decide.  It  appears  to  assume  some  difference  in 
its  form  and  train  of  symptoms.  The  history  is  from  the  pen  of  an 
accurate  observer  of  nature,  and  a  judicious  and  experienced  prac- 
titioner. 

As  Baudelocque  has  explained  the  mechanism  of  parturition, 
more  fully  and  minutely  than  almost  any  other  writer,  and  as  his 
work  on  midwifery  has  obtained  considerable  reputation  with  the 
medical  public  of  the  United  States,  it  has  been  judged  proper  oc- 
casionally, to  give  a  general  view  of  his  divisions  of  labour,  together 
with  the  several  species  of  presentations,  which  it  may  be  useful  to 
keep  in  recollection  in  actual  practice.  Some  tables,  relative  to 
this  part  of  our  subject,  from  the  last  edition  of  his  valuable  work 
that  have  not,  as  far  as  we  know,  been  hitherto  translated,  will  also 
be  given  in  the  appendix.  These,  it  is  hoped,  will  not  be  entire- 
ly devoid  of  interest,  either  to  the  student  or  practitioner. 

The  chief  mass  of  the  notes  in  Dr.  Chapman's  edition  of  our 
author's  production,  have  been,  by  permission,  retained  in  this ; 
these  are  marked  with  the  letter  C.  The  notes  added  by  the  pre- 
sent editor  have  alphabetical  references,  and  are  thus  sufficiently 
distinguished  from  those  of  the  author,  and  of  the  intelligent  editor 
of  whose  information  we  have  availed  ourselves,  and  to  whom  we 
have  just  alluded.  These  will  be  found  to  be  altogether  of  a  prac- 
tical nature,  and  are  intended  solely  to  explain,  or  illustrate  the 
text;  as  it  has  been  found  rarely  necessary  to  differ  in  sentiment 
from  one,  whose  opinions  seem  generally  to  be  founded  on  the  so- 
lid basis  of  practical  truth.  Any  additions  made  to  the  text,  or 
author's  notes,  are  included  between  brackets. 


Vlll 


The  author  has  rendered  this  fifth  edition  more  interesting,  by 
sOme  valuable  additional  matter,  amounting  to  upwards  of  one  hun- 
dred pages ;  and  the  editor  has  subjoined  a  few  notes,  which  he 
hopes  will  not  be  found  entirely  nugatory.     • 

Philadelphia,  November  9th,  1822. 


(^CD^^H^^ 


BOOK  I. 

OF  THE  STRUCTURE,  FUNCTIONS,  AND  DISEASES  OF  THE  PELVIS 
AND  UTERINE  SYSTEM,  IN  THE  UN1MPREGNATED  STATE,  AND 
DURING  GESTATION. 

CHAP.  I. 

Of  the  Bones  of  the  Pelvis. 

Section  1.  General  view  -  -  Page  i 

Section  2.  Ossa  innominata  2 

Section  3.  Sacrum  and  coccyx  5 

CHAP.  II. 

Of  the  Articulation  of  the  Bones  of  the  Pelvis,  and  their  occasional 

separation. 
Section  1.  Of  the  symphysis  pubis  7 

Section  2.  Sacro-iliac  junction  8 

Section  3.  Vertebral  junction,    and  obliquity  of 

the  pelvis  9 

Section  4.  Separation  of  the  bones  9 

Section  5.  Difference  of  the  female   from   the 

male  pelvis  -  -  -  15 

CHAP.  III. 
Of  the  Soft  Parts  which  line  the  Pelvis. 
Section  1.  Muscles  -  -  -  -  17 

Section  2.  Arteries         -  -  -  -  18 

Section  3.  Nerves  -  -  -  -  19 

Section  4.  Lymphatics  29 

CHAP.  IV. 
Of  the  Dimensions  of  the  Pelvis. 
Section  1.  Brim  and  outlet         -  -  -  21 

Section  2.  Cavity  22 

Section  3.  Pelvis  above  the  brim  24 

Section  4.  Axis  of  the  brim  and  outlet  -  2*5 

J 


CHAP.  V. 

Of  the  Head  of  the  Child,  and  its  progress  through  the  Pelvis  in 

Labour. 
Section  1.  Bones  of  the  head  -  Page  25 

Section  2.  Size  of  the  head  26 

Section  3.  Passage  of  the  head  -  -  28 

CHAP.  VI. 

Of  Diminished  Capacity  and  Deformity  of  the  Pelvis. 
Section  1.  Deformity  from  rickets  30 

Section  2.  Deformity  from  malacosteon  -  32 

Section  3.  Deformity   from   exostosis   and    tu- 
mours 35 
Section  4.  Means  of  ascertaining  the  .dimensions 

and  size  of  the  head  when  broken  down       -  39 

CHAP.  VII. 
Of  Augmented  Capacity  of  the  Pelvis        -  41 

CHAP.  VIII. 

Of  the  External  Organs  of  Generation. 

Seetion  1.  General  view  42 

Section  2.  Labia  and  nymph ae                 -  -           42 

Section  3.  Clitoris  43 

Section  4.  Urethra          ...  -           43 

Section  5.  Orifice  of  vagina  and  hymen  -           45 
CHAP.  IX. 

Of  the  Interned  Organs  of  Generation. 

Section  1.  Vagina  46 

Section  2.  Uterus  and  its  appendages  -           4S 
CHAP.  X. 
Of  the  Diseases  of  the  Organs  of  Generation. 

Section     1.  Abscess  in  the  labium  52 

Section     2.  Ulceration  of  the  labia  53 

Section     3.  Excrescences  on  the  labia  -           56 

Section     4.  Scirrhous  tumours  56 

Section     5.  Polypous  tumours                 -  -           57 

Section     6.  (Edema  58 

Section     7.  Hernia,  laceration,  &:c.         -  -          58 


XI 

Section     8.  Diseases  of  the  nymphae       -  P«ge  69 

Section     9  Diseases  of  the  clitoris           -  -           01 

Section  10.  Diseases  of  the  hymen  02 

Section   11.  Laceration  of  the  perineum  -           64 

Section  12.  Imperfection  of  the  vagina  -           00 

Section  13.  Inflammation  and  gangrene  of  the  vagina     07 

Section  14.  Induration,  ulceration,  and  polypi     -  OS 

Section  15.  Inversion  09 

Section  10.  Watery  tumour  09 

Section  17.  Hernia  70 

Section  18.  Encysted  tumour  and  varices  -           71 

Section  19.  Spongoid  tumour  72 

Section  20.  Erysipelatous  inflammation  -           72 

Section  21.  Fluor  albus  74 

Section  22.  Affections  of  the  bladder  79 

Section  23.  Excrescences  in  the  urethra  -           85 

Section  24  Deficiency  and  mal-formation  of  the  uterus  87 

Section  25.  Hysteritis  89 

Section  20.  Ulceration  of  the  uterus  90 

Section  27.  Scirro-cancer  93 

Section  28.  Tubercles  97 

Section  29.  Spongoid  tumour     -             -  100 

Section  30.  Cauliflower  excrescence  from  the  os  uteri  101 

Section  31.  Calculi        -             -             -  104 

Section  32.  Polypi        -             -             -  104 

Section  33.  Malignant  polypi     -          '  -  -         109 

Section  34.  Moles         -            -            -  110 

Section  35.  Hydatids                  -             -  112 

Section  30.  Aqueous  secretion                -  -         115 

Section  37.  Worms     -               -            -  110 

Section  38.  Tympanites             -             -  117 

Section  39.  Prolapsus  uteri        -             -  -         117 

Section  40.  Hernia        -  125 

Section  41.  Dropsy  of  the  ovarium         -  -         12G 

Section  42.  Other  diseases  of  the  ovarium  -         130 

Section  43.  Deficiency             -             -  137 

Section  44.  Diseases  of  the  tubes  and  ligaments  137 


Ml 

CHAP.  XI. 

~Qf  Menstruation  -  P(lge   131 

CHAP.  XII. 

Of  Hysteria  -  -         142 

CHAP.  XIII. 

Of  Diseased  States  of  the  Menstrual  Action. 

Section  1.  Amenorrhoea  -  145 

Section  2.  Formation  of  an  organized  substance  153 

Section  3.  Dysmenorrhea  -  -  154 

Section  4.  Copious  Menstruation  -  -         155 

Section  5.  Menorrhagia  -  -  155 

CHAP.  XIV. 

Of  the  Cessation  of  the  Menses  -         162 

CHAP.  XV. 
Of  Conception,  and  the  term  of  Gestation       -         163 

CHAP.  XVI. 

Of  the  Gravid  Uterus. 

Section  1.  Size  and  position       -  167 

Section  2.  Development  of  the  uterus,  and  state  of  its 

cervix     -             -             -  -                      169 

Section  3.  Muscular  fibres           -  -             -         170 

Section  4.  Ligaments     -             -  -                       171 

Section  5.  Vessels          -  171 

Section  6.  Of  the  foetus               -  172 

Section  7.  Its  peculiarities           -  -                       178 

Section  8.  Umbilical  cord           -  -             -         182 

Section  9.  Placenta        -  185 

Section   10.  Membranes  and  liquor  ainnii  -         191 

Section  11.  Decidua      -             -  -                       192 

CHAP.  XVII. 

Of  Sterility  -  194 

CHAP.  XVIIl. 

Of  Extra-uterine  Pregnancy. 
Section  1.  Symptoms,  progress  and  species         -         196 
"Section  2.  Treatment  -  -  -         204 


Xlll 

CHAP.  XIX. 

Of  the  Signs  of  Pregnancy  Page  206 

CHAP.  XX. 

Of  the  Diseases  of  Pregnant  Women. 

Section     1.  General  effects         -             -  -         212 

Section     2.  Febrile  state            -             -  215 

Section     3.  Vomiting     -             -             -  217 

Section     4.  Heartburn                 -  219 

Section     5.  Fastidious  taste       -  220 

Section     G.  Spasm  of  stomach  and  duodenum  220 

Section     7.  Costiveness              -             -  221 

Section     8.  Diarrhoea                 -  222 

Section     9.  Piles            -             -             -  223 

Section  10.  Affections  of  the  bladder      -  -         225 

Section   11.  Jaundice                   -  226 

Section  12.  Coloured  spots         -  226 

Section  13.  Palpitation               -  227 

Section  14.  Syncope      -  228 

Section  15.  Dyspnoea  and  cough             -  -         228 

Section  16.  Haemoptysis  and  haematemesis  -         229 

Section   17.  Headach  and  convulsions     -  -         229 

Section  18.  Toothach                 -  231 

Section  19.  Salivation                  -  232 

Section  20.  Mastodynia               -  232 

Section  21.  (Edema      -  233 

Section  22.  Ascites        ...  -         233 

Section  23.  Redundance  of  liquor  amnii  -         235 

Section  24.  Watery  discharge                  -  -         238 

Section  25.  Varicose  veins          -  239 

Section  26.  Muscular  pain          -  239 

Section  27.  Spasm  of  ureter       -  240 

Section  28.  Cramp        -             -             -  -         241 

Section  29.  Spasm  of  the  uterus             -  -         241 

Section  30.  Distention  of  the  abdomen  -         242 

Section  31.  Hernia        -  242 

Section  32.  Despondency           -             -  -         24"3 


XIV 

c       DTi  oo.  Retroversion  of  uterus  -  P 

Sed  -  on  - 

Section  -35.  Rupture  of  uterus  -  -         2  5} 

Section  36.  Abortion,  and  treatment  of  pregnant 

women  - 

Section  37,  Uterine  hemorrhage  -  -         296 

-    Faise*  pains  -  335 


BOOK  II. 

OF  PARTURITION. 
CHAP.    I. 

Of  the  Classification  of  Labours  -         343 

CHAP.  II. 
Cf.Yatural  Labour. 
Section  1.   Si   \      of  labour         -  349 

Section  2.  Duration  of  pro 

a  3.  Of  Examination         - 
-  -    Cause*       labour        ...         304 

.  lanagement  of  labour 
CHAP.  DDL 

nature  Labour       -  -         .37.5- 

CHAP.  IV. 
Of  Preternatural  Labour 
Order  1.  Presentation  of  the  breeeh         -  -         351 

Order  2.  Of  the  inferior  extremities        -  -         38  G 

Order  3.  Of  the  superior  extremities       -  -         3  -  7 

Order  4.  Of  the  trunk  -  -  -         399 

Order  5.  Of  the  face.  St  ...         399 

Order  6.  Of  the  umbilical  cord 

Order  7.  Plurality  of  children  and  monsters         -         405 
CHAP.  v. 
Of  Tedious  Labour. 
Order  1.  From  imperfection  or  irregularity  of 

muscular  action  - 

Order  2.  From  some  mechanical  impediment  425 


XV 

CHAP.  VI. 

Of  Instrumental  Labours. 
Order  1.  Cases  admitting  the  application  of  the 

forceps  or  lever  -  Page  431 

Order  2.  Cases  requiring  the  crotchet  -         442 

CHAP.  VII. 
Of  Impracticable  Labour  -         470 

CHAP.  VIII. 

Of  Complicated  Labour. 
Order  1.  Labour  complicated  with  uterine  he- 
morrhage -  476 
Order  2.  With  hemorrhage  from  other  organs  477 
Order  3.  With  syncope  -  477 
Order  4.  With  convulsions  -  478 
Order  5.  With  rupture  of  the  uterus  -  -  4S7 
Qrder  6.  With  suppression  of  urine         -  -         494 


BOOK  III. 

OF  THE  PUERPERAL  STATE. 
CHAP.  I. 

Of  the  Treatment  after  delivery  -         497 

CHAP.  II. 

Of  Uterine  Hemorrhage  -         501 

CHAP.  III. 

Of  Inversion  of  the  Uterus  -         516 

CHAP.  IV. 

Of  After-pains  -  -         523 

CHAP.  V. 

Of  Hysteralgia  -  -         525 

CHAP.  VI. 

Of  Retention  of  Part  of  the  Placenta        -        527 

CHAP.  VII. 

Of  Strangury  -  -         529 

CHAP.  VIII. 
Of  Pneumonia  -,  -         530 


XVI 

CHAP.  IX. 

Of  Spasmodic  and  Nervous  Diseases         Page  530 
CHAP.  X. 
Of  Ephemeral  Fever,  or  Weed  -         533 

CHAP.  XI. 

Of  the  Milk  Fever         -  -         536 

CHAP.  XII. 

Of  Miliary  Fever  -  -         536 

CHAP.  XIII. 

Of  Intestinal  Fever  -  -         533 

CHAP.  XIV. 

Of  Inflammation  of  the  Uterus  -         541 

CHAP.  XV. 

Of  Peritoneal  Inflammation  -         545 

CHAP.  XVI. 

Of  Peurperal  Fever         -  -         549 

CHAP.  XVII. 

Of  Swelled  Leg  -         55S 

CHAP.  XVIII. 

Of  Paralysis      -  -         563 

CHAP.  XIX. 

Of  Puerperal  Mania  and  Phrenitis  -         564 

CHAP.  XX. 

Of  Bronchocele  -  -         569 

CHAP.  XXI. 

Of  Diarrhoea  -  -         570 

CHAP.  XXII. 

Of  Inflammation  of  the  Mamma,  and  Excoriation  of 

the  Nipples  -  -         571 

CliAP.  XXIII. 

Of  Tympanites  -  -         577 

CHAP.  XXIV. 

Of  the  Signs  that  a  Woman  has  been  recently  Delivered  578 

APPENDIX 581 

TABLES     -                -----  593 


THE 

PRINCIPLES 

OP 


a 


BOOK  I. 


OF  THE  STRUCTURE,  FUNCTIONS,  AND  DISEASES  OF  THE  PELVIS 

AND  UTERINE  SYSTEM,  IN  THE  UNIMPREGNATED 

STATE,  AND  DURING  GESTATION. 


CHAP.  I. 

Of  the  Bones  of  the  Pehis. 

§  1.  GENERAL  VIEW. 

THE  practical  precepts,  and  rules  in  Midwifery,  are  easily  un- 
derstood, and  readily  acquired.  They  arise  evidently  from  the 
structure  and  actions  of  the  parts  concerned  in  parturition ;  and 
whoever  is  well  acquainted  with  this  structure  and  these  actions, 
may,  from  such  knowledge,  deduce  all  the  valuable  and  important 
directions  which  constitute  the  Practice  of  Midwifery. 

One  of  the  first,  and  not  the  least  important,  of  the  parts  con- 
cerned in  parturition,  is  the  pelvis,  which  must  be  examined,  not 
only  on  account  of  its  connection  with  the  uterus  and  vagina,  but 
also  of  its  own  immediate  relation  to  the  delivery  of  the  child,  and 
the  obstacles  which,  in  many  instances,  it  opposes  to  its  passage. 

The  pelvis  consists  in  the  full  grown  female,  of  three  large 
bones,  two  of  which  are  very  irregular,  having  no  near  resemblance 
to  any  other  object ;  on  which  account  they  have  been  called  the 

2 


2 

ossa  iunoininata.  These  form  the  sides  and  front  of  the  basin  or 
pelvis.  The  back  part  consists  of  a  triangular  bone,  called  the  os 
sacrum,  to  the  inferior  extremity  or  apex  of  which,  is  attached, 
by  a  moveable  articulation,  a  small  bone,  which  from  its  supposed 
resemblance  to  the  beak  of  a  cuckoo,  has  been  named  the  os  coc- 
cygis. 

The  os  innominatum,  in  infancy,  consists  of  three  separate 
pieces :  the  upper  portion  is  called  the  ilium,  or  haunch  bone ; 
the  under,  the  ischium,  or  seat  bone;  and  the  anterior,  which  is 
the  smallest  of  the  three,  is  called  the  os  pubis,  or  share  bone* 
These  all  join  together  in  the  acetabulum,  or  socket,  formed  for 
receiving  the  os  femoris,  and  are  connected  by  a  very  firm  gristle 
or  cartilage.  This,  before  the  age  of  puberty,  is  converted  into 
bone,  so  that  the  three  different  pieces  are  consolidated  into  one, 
though  the  names  given  to  the  bones  originally  are  still  applied  to 
the  different  parts  of  the  united  os  innominatum. 

The  sacrum  also,  which  seems  to  consist  only  of  one  curved 
triangular  bone,  is  really  made  up  of  several  pieces,  which,  in  the 
child,  are  nearly  as  distinct  as  the  vertebrae,  to  which,  indeed,  they 
bear  such  a  resemblance,  that  they  have  been  considered  as  a  con- 
tinuation of  them  ;  but  from  their  imperfect  structure,  and  subse- 
quent union,  they  have  been  called  the  false  vertebra?. 

The  bones  of  the  pelvis  are  firmly  joined  together,  by  means  of 
ligaments  and  intermediate  cartilages,  and  form  a  very  irregular 
canal,  the  different  parts  of  which  must  be  briefly  mentioned. 

§  2.  OSSA  INNOM1NATA. 

When  we  look  at  the  pelvis,  we  observe,  that  the  ossa  innomi- 
nata  naturally  divide  themselves  into  two  parts,  the  uppermost  of 
which  is  thin  and  expanded,  irregularly  convex  on  its  dorsum  or 
outer  surface,  hollow  on  the  inside,  which  is  called  the  costa,  and 
bounded  by  a  broad  margin,  extending  in  a  semicircular  direction 
from  before  backwards,  which  is  called  the  crest  of  the  ilium. 
The  under  part  or  the  os  innominatum  is  very  irregular,  and  forms, 
with  the  sacrum,  the  cavity  of  the  pelvis.  The  upper  expanded 
part  has  little  influence  on  labour,  and  serves,  principally,  for  af- 


3 

fording  attachment  to  muscles.     In  the  under  part,  we  have  seve- 
ral points  to  attend  to. 

1st.  The  upper  and  under  parts  form  an  angle  with  each  other, 
marked  by  a  smooth  line ;  which  is  a  continuation  of  the  margin  of 
the  pubis,  or  anterior  part  of  the  bone.  It  extends  from  the  sym- 
physis pubis,  all  the  way  to  the  junction  of  the  os  innominatura 
with  the  sacrum,  and  is  called  the  linea  iliopectinea.  It  is  quite 
smooth  and  obtuse  at  the  sides,  where  the  tw<£  portions  form  an 
angle ;  but  at  the  anterior  part,  where  the  upper  portion  is  want- 
ing, it  is  sharp,  and  sometimes  is  elevated  into  a  thin  spine  like  the 
blade  of  a  knife. 

2d.  The  upper  portion  is  discontinued  exactly  about  the  middle 
of  this  line,  or  just  over  the  acetabulum  ;  and  at  the  termination, 
there  is  from  this  portion  an  obtuse  projection  overhanging  the  ace- 
tabulum, which  is  called  the  inferior  spinous  process  of  the  ilium, 
to  distinguish  it  from  a  similar  projection  about  half  an  inch  higher, 
called  the  superior  spine. 

3d.  The  under  part  of  the  bone  is  of  the  greatest  importance, 
and  in  it  we  recognise  the  following  circumstances.  Its  middle  is 
large,  and  forms  on  the  outside  a  deep  cup  or  acetabulum,  for  the 
reception  of  the  head  of  the  thigh  bone.  On  the  inside,  and  just: 
behind  this  cup,  it  forms  a  smooth  polished  plate  of  bone  within 
the  cavity  of  the  pelvis,  which  is  placed  obliquely  with  regard  to 
the  pubis,  and  has  a  gentle  slope  forward.  The  cone  of  the  child's 
head,  in  labour,  moves  downwards,  and  somewhat  forwards,  on 
this,  as  on  an  inclined  plane ;  it  may  be  called  the  plane  of  the 
ischium,  although  a  part  of  it  be  formed  by  the  ilium. 

4th.  Standing  off  from  the  back  part  of  this,  about  two  inches 
beneath  the  linea  iliopectinea,  is  a  short  projection,  called  the  spine 
of  the  ischium,  which  seems  to  encroach  a  little  on  the  cavity  of 
the  pelvis,  and  is  placed,  with  regard  to  the  pubis,  still  more 
obliquely  than  the  plane  of  the  ischium.  It  must,  consequently, 
tend  to  direct  the  vertex,  as  it  descends,  still  more  towards  the 
pubis. 

5th.  Beneath  this,  the  ischium  becomes  narrower,  but  not  thin- 
ner ;  on  the  contrary,  it  is  rather  thicker,  and  terminates  in  a  rough 
bump,  called  the  tuberosity  of  the  ischium. 


6th.  Next,  we  look  at  the  anterior  part  of  the  bone,  and  find, 
that  just  before  the  plane  of  the  ischium,  there  is  a  large  hole  in 
the  os  innominatum.  This  is  somewhat  oval  in  its  shape;  and  at 
the  upper  part  within  the  pelvis,  there  is  a  depression  in  the  bone, 
which,  if  followed  by  the  finger  or  a  probe,  leads  to  the  face  of  the 
pelvis.     The  hole  is  called  the  foramen  thyroideum. 

7th.  Before  this  hole  the  two  ossa  innominata  join,  but  form 
with  each  other  oh  the  inside,  a  very  obtuse  angle,  or  a  kind  of 
smooth  rounded  surface,  on  which  the  bladder  partly  rests.  The 
junction  is  called  the  symphysis  of  the  pubis. 

8th.  The  two  bones,  where  they  form  the  symphysis,  are  joined 
with  each  other  for  about  an  inch  and  a  half;  then  they  divaricate, 
forming  an  angle,  the  limbs  of  which  extend  all  the  way  to  the  tu- 
berosity of  the  ischium.  This  separation  or  divarication  is  called 
the  arch  of  the  pubis,  which  is  principally  constructed  of  the  ante- 
rior boundary  of  the  foramen  thyroideum,  consisting  of  a  columa 
or  piece  of  bone,  about  half  an  inch  broad,  and  one-fourth  of  an 
inch  thick,  formed  by  the  union  of  the  ramus  of  the  pubis,  and 
that  of  the  ischium. 

9th.  At  the  upper  part  of  the  symphysis,  or  a  very  little  from 
it,  the  os  innominatum  has  a  short  obtuse  projection,  called  the 
crest  of  the  pubis,  into  which  Poupart's  ligament  is  inserted ;  and 
from  this  there  runs  down  obliquely,  a  ridge  on  the  outside  of  the 
bone,  which  reaches  all  the  way  to  the  acetabulum,  and  overhangs 
the  foramen  thyroideum. 

10th.  When  we  return  to  the  back  part  of  the  os  innominatum, 
we  find,  that  just  after  it  has  formed  the  plane  of  the  ischium,  it 
extends  backwards  to  join  the  sacrum  ;  but  in  doing  so,  it  forms  a 
very  considerable  notch  or  curve,  the  concavity  of  which  looks 
downwards.  When  the  sacrum  is  joined  to  the  bone,  this  notch  is 
much  more  distinct.  It  is  called  the  sacro-sciatic  notch  or  arch  : 
for  one  side  is  formed  by  the  ischium,  and  is  about  two  inches 
long ;  the  other  is  formed  chiefly  by  the  sacrum,  and  is  about  half 
an  inch  longer.  In  the  recent  subject,  strong  ligaments  are  ex- 
tended at  the  under  part,  from  one  bone  to  the  other,  so  that  this 
notch  is  converted  into  a  regular  oval  hole. 

11th.  Lastly,  this  notch  being  formed,  the  bone  expands  back- 


wards,  forming  a  very  irregular  surface  for  articulation  with  the 
sacrum ;  and  the  bones  being  joined,  we  find  that  the  os  innomi- 
natum  forms  a  strong,  thick,  projecting  ridge,  extending  farther 
back  than  the  spinous  processes  of  the  sacrum.  This  ridge  is 
about  two  inches  and  three  quarters  long,  and  is  a  continuation  of 
the  crest  of  the  ilium,  but  is  turned  downwards;  whereas  were  the 
crest  continued  in  its  former  course,  it  would  meet  with  the  one 
from  the  opposite  side,  behind  the  top  of  the  sacrum,  forming  thus 
a  neat  semicircle ;  but  this  ridge,  if  prolonged  on  both  sides, 
would  form  an  acute  angle,  the  point  of  junction  being  opposite 
the  bottom  of  the  sacrum.  From  this  strong  ligaments  pass  to  the 
sacrum,  to  join  the  two  bones. 

§  3.  SACRUM  AND  COCCYX. 

The  sacrum  forms  the  back  part  of  the  pelvis.  It  is  a  triangular 
bone,  and  gently  curved  ;  so  that,  whilst  a  line  drawn  from  the 
one  extremity  to  the  other,  measures,  if  it  subtend  the  arch,  about 
four  inches  ;  it  will,  if  carried  along  the  surface  of  the  bone,  mea- 
sure full  half  an  inch  more.  The  distance  betwixt  the  first,  or 
straight  line,  and  the  middle  of  the  sacrum  is  about  one  inch.  The 
breadth  of  the  base  of  the  sacrum,  considered  as  an  angular  body, 
is  full  four  inches  :  the  centre  of  this  base  is  shaped  like  the  sur- 
face of  the  body  of  one  of  the  lumbar  vertebrae,  with  the  last  of 
which  it  joins,  forming,  however,  an  angle  with  it,  called  the  great 
angle,  or  promontory  of  the  sacrum,  (a)  From  this  the  bone  is 
gently  curved  outward  on  each  side,  toward  the  sacro-iliac  junc- 
tion, contributing  to  the  formation  of  the  brim  of  the  pelvis. 

The  upper  half  of  the  side  of  the  bone  is  broad  and  irregular  for 
articulation  with  the  os  innominatum.  The  anterior  surface  of  the 
bone  is  smooth  and  concave ;  but  often  we  observe  transverse 
ridges,  marking  the  original  separation  of  the  bones  of  the  sacrum. 
Four  pair  of  holes  are  found  disposed  in  two  longitudinal  rows  on 
the  face  of  the  sacrum,  communicating  with  the  canal  which  re- 
ceives the  continuation  of  the  spinal  marrow ;  through  these  the 

(«)  But  more  commonly  the  projection  of  the  sacrum. 


sacr.il  nerves  issue.  These  holes  slope  a  little  outward,  and  be- 
twixt the  two  rows  is  the  attachment  of  the  rectum.  The  posterior 
surface  of  the  bone  is  very  irregular  ;  and  wre  observe,  1st.  The 
canal  extending  down  the  bone,  for  receiving  the  continuation  of 
the  spinal  marrow.  2d.  At  the  upper  part  of  this  are  two  strong 
oblique  processes,  which  join  with  those  of  the  last  lumbar  ver- 
tebra. 3d.  On  a  central  line  down  the  back  of  the  canal,  there  is 
an  irregular  ridge  analogous  to  the  spines  of  the  vertebrae.  4th. 
The  rest  of  the  surface  is  very  irregular  and  rough ;  and  we  ob- 
serve, corresponding  to  the  holes  for  transmitting  the  sacral  nerves 
on  the  exterior  surface,  the  same  number  of  foramina  on  this  pos- 
terior surface,  but,  in  the  recent  subject,  they  are  covered  with 
membrane,  leaving  only  a  small  opening  for  the  exit  of  nervous 
twigs. 

The  coccyx  is  an  appendage  to  the  sacrum,  and  as  it  is  inclined 
forwards  from  that  bone,  the  point  of  junction  has  been  called  the 
little  angle  of  the  sacrum.  It  is,  at  first,  altogether  cartilaginous, 
and  cylindrical  in  its  shape,  but  it  gradually  ossifies  and  becomes 
flatter,  especially  at  the  upper  part,  which  has  been  called  its 
shoulder.  In  men  it  is  generally  anchylosed  with  the  sacrum,  or 
at  least  moves  with  difficulty,  but  it  almost  always  separates  by 
maceration.  In  women  it  remains  mobile,  and,  during  labour,  is 
pressed  back  so  as  to  enlarge  the  outlet  of  the  pelvis.  By  falls  or 
blows  it  may  be  luxated ;  and  if  this  be  not  discovered,  and  the 
bone  replaced,  suppuration  takes  place  about  the  rectum,  and  the 
bone  is  discharged^ 


CHAP.  II. 

Of  the  Articulation  of  the  Bones  of  the  Pelvis,  and  their  occasional 

separation. 

§  1.  OF  THE  SYMPHYSIS  PUBIS. 

The  bones  of  the  pelvis  are  connected  to  each  other,  by  inter-, 
mediate  cartilages,  and  by  very  strong  ligaments.  The  ossainno- 
minata  are  united  to  each  other  at  the  pubis,  in  a  very  strong  and 
peculiar  manner.  It  was  supposed  that  they  were  joined  together 
by  one  intermediate  cartilage ;  but  Dr.  Hunter*  was,  from  his  ob- 
servations, led  to  conclude,  that  each  bone  was  first  of  all  covered 
at  its  extremity  with  cartilage,  and  then  betwixt  the  two  was  inter- 
posed a  medium,  like  the  intervertebral  substance,  which  united 
them.  This  substance  consists  of  fibres  disposed  in  a  transverse 
direction. 

M.  Tenonf  has  lately  published  an  account  of  this  articulation  ; 
and  is  of  opinion,  that  sometimes  the  one  mode  and  sometimes  the 
other  obtains.  I  am  inclined  to  think,  that  Dr.  Hunter's  descrip- 
tion is  applicable  to  the  most  natural  state  of  the  part ;  but  we  often. 
ln  females,  find  that  the  intermediate  fibrous  substance,  especially 
at  the  posterior  part,  is  absorbed,  and  its  place  supplied  with  a 
more  fluid  substance  ;  or,  on  the  contrary,  anchylosis  may  some- 
times take  place;  a  circumstance  which  Dr.  Hunter  says  he  never 
saw,  but  which  I  have  met  with.  Besides  this  mode  of  connection, 
there  is  also  in  addition  a  very  strong  capsule  to  the  articulation, 
the  symphysis  being  covered  on  every  side  with  ligamentous 
fibres,  which  contribute  greatly  to  the  strength  of  the  parts. 

*  Vide  Med.  Obs.  and  Inq.  Vol.  II.  p.  333. 

f  Vide  Mem.  de  l'lnstittlt  des  Sciences,  Tome  VI.  p.  lf£. 


§  2.  SACROJLIAC  JUNCTION, 

The  ossa  innominata  are  joined  to  the  sacrum  by  means  of  a 
thin  layer  of  cartilaginous  substance,  which  covers  each  bone ; 
that  belonging  to  the  sacrum  is  the  thickest :  both  are  rough,  and 
betwixt  them  is  found  a  soft  yellowish  substance  in  small  quantity. 
The  connection  of  the  two  bones  therefore,  so  far  as  it  depends  on 
this  medium,  cannot  be  very  strong;  but  it  is  exceedingly  strength- 
ened by  ligamentous  fibres,  which  serve  as  a  capsule;  and  behind, 
several  strong  bands  pass  from  the  ridge  of  the  ilium  to  the  back 
of  the  sacrum ;  sometimes  the  bones  are  united  by  anchylosis.  At 
the  lower  part,  additional  strength  is  obtained  by  two  large  and 
strong  ligaments,  which  pass  from  the  ischium  to  the  sacrum,  and 
therefore  are  called  the  sacro-sciatic  ligaments.  The  innermost  of 
these  arises  from  the  spine  of  the  ischium,  is  very  strong,  but  at 
first  not  above  a  quarter  of  an  inch  broad ;  it  gradually  expands, 
however,  becoming  at  its  insertion  about  an  inch  and  a  quarter  in 
breadth.  It  passes  on  to  the  sacrum,  and  is  implanted  into  the 
lower  part  of  the  side  of  that  bone,  and  the  upper  part  of  the 
coccyx.  It  converts  the  sacro-sciatic  notch  into  a  regular  oval 
hole,  the  inferior  end  of  which,  owing  to  the  neat  expansion  of 
the  ligament,  is  as  round  and  exact  as  the  upper.  As  it  makes  a 
similar  expansion  downwards,  there  is  a  kind  of  semilunar  notch 
formed  betwixt  it  and  the  coccyx.  The  outer  ligament  may  be 
said  to  arise  from  the  side  of  the  sacrum,  and,  like  the  other,  is 
broad  at  that  part.  It  runs  for  some  time  in  contact  with  the  inner 
ligament,  and  parallel  to  it ;  but  afterwards  it  separates,  passing 
down  to  be  inserted  in  the  tuber  ischii ;  and,  when  the  ligaments 
separate,  their  surfaces  are  no  longer  parallel  to  each  other.  There 
is,  in  consequence  of  this  separation,  a  small  triangular  opening 
formed  betwixt  the  ligaments  ;  or  rather  there  is  an  aperture  like 
a  bow,  the  string  being  formed  by  the  under  ligament,  and  the 
arch  partly  by  the  spine  of  the  ischium,  and  partly  by  the  upper 
ligament. 


9 

§  3.  VERTEBRAL  JUNCTION  AND  OBLIQUITY  OF  THE  PELVIS. 

The  pelvis  is  joined  to  the  trunk  above,  by  means  of  the  last 
lumbar  vertebra ;  to  the  extremities  below,  by  the  insertion  of  the 
thigh  bones  into  the  acetabula  ;  and  it  is  so  placed,  that  when  the 
body  is  erect,  the  upper  part  of  the  sacrum  and  the  acetabula  are 
nearly  in  the  same  line.  The  brim  of  the  pelvis,  then,  is  neither 
horizontal  nor  perpendicular  to  the  horizon,  but  oblique,  being 
placed  at  an  angle  of  35  or  40  degrees.  Were  the  ligaments  of  the 
pelvis  loosened,  there  would,  from  this  position,  be  a  tendency  in 
the  sacrum  to  fall  directly  towards  the  pubis,  the  ossa  innominata 
receding  on  each  side.  But  the  structure  of  the  part  adds  greatly 
to  the  power  of  the  ligaments;  for  it  is  to  be  observed,  that  in 
standing,  and  in  various  exertions  of  the  body,  the  limbs  react  on 
the  pelvis  ;  and  the  heads  of  the  thigh  bones  pressing  on  the  two 
acetabula,  force  the  ossa  innominata  more  closely  on  each  other 
at  the  symphysis,  and  more  firmly  on  the  sacrum  behind.  It  is 
not  possible,  indeed,  to  separate  the  bones  of  the  pelvis,  unless  the 
connecting  ligaments  be  diseased,  or  external  violence  be  applied, 
so  as  to  act  partially  or  unequally  on  the  pelvis. 

§  4.  SEPARATION  OF  THE  BONES. 

By  external  violence,  the  symphysis  has  been  wrenched  open, 
as  was  the  case  with  Dr.  Greene  ;*  or  the  sacro-iliac  junction  may 
be  separated,  as  in  the  case  of  the  young  peasant,  related  by  M. 
Louis.f 

By  some  morbid  affection  of  the  symphysis,  it  may  yield  and 
become  loosened  during  pregnancy,  or  may  be  separated  during 
labour.  Some  have  been  inclined  to  consider  this  as  an  uniform 
operation  of  nature,  intended  to  facilitate  the  birth  of  the  child. 
Others,  who  cannot  go  this  length,  have  nevertheless  conjectured 
that  the  ligaments  do  become  somewhat  slacker;  and  have  ground- 
ed this  opinion  on  the  supposed  fact  of  the  pelvis  of  quadrupeds 

*  Phil.  Trans.  No.  484. 

|  Vide  Mem.  de  l'Acad.  de  Chir.  Tome  IV.  p.  63. 

3 


10 

undergoing;  this  relaxation.  But  the  truth  is,  that  this  separation 
is  not  an  advantage,  but  a  serious  evil ;  and  in  cases  of  deformed 
pelvis,  where  we  would  naturally  look  for  its  operation,  did  it 
really  exist,  we  do  not  observe  it  to  take  place.* 

*  Desault  and  Beclard  maintain  that  the  articulations  loosen,  and  Boyer  says 
that  in  one  case,  he  found  the  sacro-iliac  connection  separated  to  the  extent  of 
half  an  inch  ;  Chaussier,  that  he  found  the  symphysis  of  the  pubis  separated  to 
a  greater  degree,  in  an  easy  labour.  Gardien  observes  that  it  only  happens 
where  there  is  a  predisposition,  for  the  head  is  too  soft  to  force  asunder  the 
bones  of  the  pelvis.  Pare  and  Louis,  and  more  lately  Piet,  suppose  that  the 
separation  proceeds  from  swelling  of  the  cartilages  and  simple  extension  of  the 
ligaments;  an  opinion  which  Chaussier  says  he  has  confirmed  by  dissection. 
Baudelocque,  on  the  other  hand,  asserts  that  it  proceeds  from  extension  of  the 
ligament  alone,  the  cartilages  remaining  the  same  in  thickness.  Pinault  thought 
that  the  process  of  relaxation  might  be  promoted  by  the  use  of  baths  and  blood- 
letting; but  this  is  correctly  denied  by  Gardien,  although  both  imagine  that  the 
relaxation  is  beneficial.  Yet  the  continental  calculators  admit,  that,  in  order  to 
gain  two  lines  in  the  anteroposterior  diameter,  there  must  be  a  separation  of 
the  pubis  to  the  extent  of  one  inch.  Perhaps  to  obviate  an  objection  which 
might  be  brought  against  the  benefit  of  this  natural  separation,  Plessman  says 
that  all  the  three  articulations  relax  simultaneously,  and  thereby  a  greater  ad- 
vantage is  gained  with  less  injury  to  the  individual  joinings,  fbj 

(~bj  There  is  an  animal,  however,  in  which  this  separation  of  the  bones  of 
the  pelvis  during  pregnancy  and  parturition  does  really  take  place,  and  in  whom 
it  appears  to  be  an  operation  of  nature  to  facilitate  the  latter  process. — This 
animal  is  the  Guinea  Pig. 

Le  Gallois  says,  that  upon  comparing  the  pelvis  of  the  female  of  the  Guinea 
Pig  with  the  head  of  a  full  grown  Foetus,  it  appears  utterly  impossible,  that  the 
latter  should  pass  through  the  former,  if  the  pelvis  constantly  preserved  the 
state  and  dimensions  at  any  other  time  than  that  of  gestation. 

When  the  female  Guinea  Pig  is  alive,  the  diameter  of  the  pelvis  is  asserted  to 
be  but  about  one-half  of  the  head  of  the  Foetus;  and  nevertheless,  Guinea  Pigs 
are  delivered  with  much  ease. 

The  duration  of  gestation  in  these  animals  being  about  65  days — About  three 
weeks  before  delivery,  the  symphysis  pubis  is  observed  to  acquire  more  thick- 
ness and  a  slight  mobility  ;  these  are  continually  increasing.  Eight  or  ten  days 
before  delivery,  the  two  ossa  pubis  begin  to  separate  from  each  other.  This 
separation  increases  slowly  at  first,  and  only  begins  to  go  on  rapidly  for  the  three 
or  four  days  which  precede  delivery. — At  the  moment  of  parturition,  according 
to  Le  Gallois,  it  is  such  as  readily  to  admit  the  middle  finger,  and  sometimes 
both  the  middle  and  fore  finger  together. 

The  delivery  being  accomplished,  the  bones  of  the  pubis  soon  close.  Twelve 
hours  after,  the  distance  of  the  separation  has  lessened  more  than  one  half;  and 


11 

When  a  person  stands,  pressure  is  made  upon  the  symphysis, 
and  therefore,  if  it  be  tender,  pain  will  then  be  felt.  In  walking, 
pressure  is  made  on  the  two  acetabula  alternately,  and  the  ossa 
innominata  are  acted  on  by  the  strong  muscles  which  pass  from 
them  to  the  thighs,  so  that  there  is  a  tendency  to  make  the  one  os 
pubis  rise  above  the  other ;  but  this,  in  a  sound  state  of  the  parts, 
is  sufficiently  resisted  by  the  ligaments.  In  a  diseased  state,  how- 
ever, or  in  a  case  of  separation  of  the  bones,  there  is  not  the  same 
obstacle  to  this  motion :  and  hence,  walking  must  give  great  pain, 
or  be  altogether  impossible  :  even  attempts  to  raise  the  one  thigh 
above  the  other,  in  bed,  must  give  more  or  less  pain,  according  to 
the  sensibility  or  laxity  of  the  symphysis.  Standing  has  also  an 
effect  on  the  symphysis,  as  I  have  mentioned  ;  but  sometimes  the 
person  can,  by  fixing  one  os  innominatum,  with  all  the  muscles 
connected  with  it,  and  throwing  the  chief  weight  of  the  body  to 
that  side,  stand,  for  a  short  time,  easier  on  one  leg  than  on  both. 
This  is  the  case,  when  one  os  innominatum  has  been  more  acted 
on  than  the  other,  at  the  sacro-iliac  junction.  The  person  can  stand 
easiest  on  the  soundest  side.  The  patient  also,  especially  if  the 
relaxation  be  accompanied  with  any  degree  of  relaxation  of  ute- 
rine attachments,  instinctively  crosses  her  legs  when  standing, 
thereby  obtaining  relief. 

From  these  observations,  we  may  learn  the  mischievous  conse- 
quences of  a  separation  of  the  bones,  and  also  the  circumstances 
which  will  lead  us  to  suspect  that  it  has  happened.  If  the  bones 
be  fully  disjoined,  then,  by  placing  the  finger  on  the  inside  of  the 
symphysis,  and  the  thumb  on  the  outside,  we  can  readily  perceive 
a  jarring  or  motion,  on  raising  the  thigh. 

It  is  well  known  to  every  practitioner,  that  owing  to  the  disten- 
sion of  the  muscles  during  pregnancy,  very  considerable  pain  is 
sometimes  felt  at  the  insertion  of  the  rectus  muscle  into  the  pubis ; 
and  it  is  also  known,  that  sometimes,  in  consequence  of  pregnancy, 
the  parts  about  the  pelvis,  and  especially  the  bladder  and  urethra,  and 

24  hours  after,  they  are  in  contact  at  their  anterior  extremity  ;  and  in  less  than 
three  days  they  are  perfectly  so  through  the  whole  extent  of  their  symphysis, 
which  then  only  presents  a  slight  thickness  and  mobility.  A  few  days  after, 
nothing  is  to  be  seen.  But  when  the  females  are  old  or  sick,  the  union  takes 
place  more  slowly.     Vide  Le  Gallois's  experiments. 


12 

even  the  whole  vulva  may  become  very  irritable.  This  tender  state 
may  be  communicated  to  the  symphysis;  or  some  irritation,  less  in 
degree  than  that  I  have  mentioned  may  exist,  which,  in  particular 
cases,  seems  to  extend  to  the  articulation,  producing  either  an 
increased  effusion  of  interstitial  fluid  in  the  intermediate  carti- 
lage, and  thus  loosening  the  firm  adhesion  of  the  bones,  or  a  ten- 
derness and  sensibility  of  the  part,  rendering  motion  painful.  In 
either  case,  exertion  may  produce  a  separation  :  and  certainly,  in 
some  instances,  has  done  so.  The  separation  is  always  attended 
with  inconvenience,  and  often  with  danger,  especially  when  it  oc- 
curs during  parturition ;  for  abscess  may  take  place,  and  the  pa- 
tient sink  under  hectic  fever  ;  or  inflammation  may  be  communi- 
cated to  the  peritoneum,  and  the  patient  die  in  gr£at  pain. 

When  the  accident  happens  during  gestation,  it  sometimes  takes 
place  gradually,  in  consequence  of  an  increasing  relaxation  of  the 
articulation,  from  slow  but  continued  irritation.  In  the  other  in- 
stances, it  happens  suddenly  after  some  exertion.  It  may  occur  so 
early  as  the  second,  or  so  late  as  the  ninth  month,  and  is  discovered 
by  the  symptoms  mentioned  above ;  such  as  pain  at  the  pubis, 
strangury,  and  the  effects  of  motion.  In  some  instances,  consi- 
derable fever  may  take  place,  but  in  general,  the  symptoms  are 
not  dangerous,  and  I  do  not  know  any  case  which  has  terminated 
fatally  before  delivery.  A  state  of  strict  rest,  the  application  of  a 
broad  firm  bandage  round  the  pelvis,  to  keep  the  bones  steady, 
and  the  use  of  the  lancet  and  antiphlogistic  regimen,  if  there  be 
fever  or  much  pain,  are  the  chief  points  of  practice.  Nor  must  it 
be  forgotten  for  a  moment,  that  although  by  these  means,  the  symp- 
toms are  removed,  the  patient  is  liable,  during  the  remaining  term 
of  gestation,  or  at  the  time  of  delivery,  to  a  renewal  of  the  relaxa- 
tion or  separation,  from  causes  which,  in  other  circumstances, 
would  have  had  no  effect.  So  far  as  I  have  been  able  to  learn,  a 
woman  who  has  had  this  separation  in  one  pregnancy,  is  not,  in 
general,  peculiarly  liable  to  a  return  of  it  in  a  subsequent  preg- 
nancy, though  there  may  be  particular  exceptions  to  this  obser- 
vation.* 

*  Dr.  Denman  mentions  an  instance,  where  the  patient,  in  three  succeeding 
pregnancies,  was  progressively  worse,  and  did  not,  until  the  lapse  of  eight 
years,  recover  from  the  lameness  produced  by  the  third  delivery,  lntrod. 
Vol.  I.  p.  16. 


13 

When  it  happens  during  parturition,  it  sometimes  takes  place  in 
a  pelvis  apparently  previously  sound;  but  in  most  instances,  we 
have,  during  some  period  of  gestation,  symptoms  of  disease  about 
the  symphysis ;  and  so  far  from  making  labour  easier,  the  woman 
often  suffers  more  when  the  symphysis  is  previously  relaxed.  The 
primary  and  immediate  effects  are  the  same  as  when  the  accident 
happens  during  pregnancy  ;  but  the  subsequent  symptoms  are  fre- 
quently much  more  severe  and  dangerous,  the  tendency  to  inflam- 
mation being  strong.  The  pain  may  be  either  trifling  or  excru- 
ciating at  the  moment,  according  to  the  sensibility  of  the  parts. 
But  even  in  the  mildest  case,  great  circumspection  is  required, 
violent  inflammation  having  come  on  so  late  as  a  fortnight  after 
the  accident.  The  means  used  in  the  former  case  are  to  be  rigidly- 
employed,  and  the  woman  should  keep  her  thighs  together,  and 
lie  chiefly  on  her  back.  If  the  separation  have  been  slight,  re- 
union may  take  place  in  a  few  weeks,  sometimes  in  a  month  ;*  but 
if  a  great  injury  have  been  sustained,  it  may  be  many  months,  per- 
haps years  before  recovery  be  completed ;  and,  in  such  cases,  it  is 
probable,  that  at  last,  an  anchylosis  is  sometimes  formed. 

Either  owing  to  the  violence  of  the  accident,  or  the  peculiar 
state  of  the  parts,  it  sometimes  happens  that  inflammation  takes 
place  to  a  very  considerable  degree  in  the  symphysis ;  but  it  is  to 
be  remarked,  that  the  symptoms  are  by  no  means  uniformly  pro- 
portioned in  their  severity  to  the  degree  of  the  separation.  Inflam- 
mation is  known  by  the  accession  of  fever,  with  acute  pain  about 
the  lower  part  of  the  belly,  greatly  increased  by  motion,  succeed- 
ing to  the  primary  effects ;  or,  sometimes,  from  the  first,  the  pain 
is  very  great,  and  not  unfrequently  it  is  accompanied  by  sympa- 
thetic derangement  of  the  stomach  and  bowels,  such  as  vomiting, 
nausea,  looseness,  Sic.  Presently  matter  forms,  and  a  well  marked 
hectic  state  takes  place.  The  patient  is  to  be  treated,  at  first,  by 
the  usual  remedies  for  abating  inflammation,  such  as  general  and 
local  evacuation  of  blood,  fomentations,  and   laxatives.     When 

*  In  one  case,  where  the  symphysis  was  divided,  the  patient  was  able  to  walk 
on  the  15th  day. — In  Dr.  Smollet's  case,  although  in  the  eighth  month  of  gesta- 
tion, the  bones  were  found  to  rise  above  each  other,  yet  the  woman  recovered  in 
two  months  after  delivery.     Smellie,  Vol.  II.  col.  1.  n.  i.  c.  2. 


14 

matter  is  formed,  we  mu^t  carefully  examine  where  it  is  most 
exposed,  and  let  it  out  by  a  small  puncture  * 

The  inflammation  may  be  communicated  to  the  peritoneum, 
producing  violent  pain  in  the  lower  belly,  tumefaction  and  fever, 
and  almost  uniformly  proves  fatal ;  though  frequently  the  patient 
lives  until  abscess  takes  place  in  the  cellular  substance  within  the 
pelvis.  If  any  thing  can  save  her,  it  must  be  the  prompt  use  of 
blood-letting  and  blisters. 

In  almost  every  case  of  separation  of  the  pubis,  considerable 
pain  is  felt  in  the  loins,  even  although  the  junction  at  the  sacrum 
be  entire,  and  the  ossa  pubis  be  very  little  asunder.  But  when  the 
separation  is  complete,  and  in  any  way  extensive,  then  the  articu- 
lation of  the  sacrum  with  the  ossa  innominata,f  especially  with  one 

*  As  an  illustration  of  this  disease,  I  shall  relate  the  outlines  of  a  case  men- 
tioned by  Louis,  in  the  Memoirs  of  the  Royal  Academy  of  Surgery.  A  woman  in 
the  second  month  of  her  pregnancy,  after  pressing  in  a  drawer  with  her  foot, 
felt  a  considerable  pain  at  the  lower  part  of  the  belly,  greatly  increased  by 
every  change  of  posture  ;  and  along  with  this  she  complained  of  strangury. 
She  was  bled,  and  purged,  and  kept  at  rest,  by  which  means,  especially  by  the 
last,  she  grew  better.  But  in  the  two  latter  months  of  pregnancy,  the  symptoms 
were  renewed,  so  that  presently  she  could  neither  walk,  nor  even  turn  in 
bed,  without  great  pain ;  but  her  greatest  suffering  was  caused  by  raising  the 
legs  to  pull  on  her  stockings,  as  then  the  bones  were  more  powerfully  acted  on. 
A  slight  degree  of  hectic  fever  now  appeared.  Her  deliver}-  was  accomplished 
easily ;  but  on  the  evening  of  the  third  day,  when  straining  at  stool,  after  having 
received  a  clyster,  the  pain,  which  had  troubled  her  little  since  her  labour,  re- 
turned with  as  much  severity  as  ever.  On  the  5th  day  the  pulse  was  very  weak 
and  frequent,  she  sweated  profusely,  and  had  a  wildness  in  her  countenance,  with 
symptoms  of  approaching  delirium.  In  the  afternoon  the  pulse  became  full  and 
tense,  with  vertigo  and  throbbing  of  the  arteries  of  the  head.  The  pain  at  the 
symphysis  was  excruciating,  and  although  she  was  fomented  and  bled  seven 
times,  she  obtained  no  relief.  On  the  8th  day  the  pain  abated,  but  diffused  itself 
over  the  rest  of  the  pelvis,  particularly  affecting  the  left  hip  and  the  sacrum. 
On  the  11th  day  she  died.  On  opening  the  body,  there  was  found  a  separation 
of  the  bones  at  the  pubis,  but  the  capsule  was  entire,  and  much  distended.  It 
contained  about  an  ounce  and  a  half  of  matter.  Whether  the  tVmeous  evacuation 
of  this  matter  might  have  saved  the  patient,  is  a  question  worth  our  consideration. 
I  am  disposed  to  answer  it  in  the  affirmative,  from  observing,  that  wherever  the 
patient  has  recovered  in  such  circumstances,  it  has  uniformly  happened,  that  a 
discharge  of  matter  has  taken  place. 

f  Dr.  Laurence  shewed  Dr.  Smellie  a  pelvis,  where  all  the  bones  were  sepa- 
rated to  the  extent  of  an  inch. 


15 

of  them,  is  more  injured,*  and  the  person  is  lame  in  one  or  both 
sides,  and  has  acute  pain  about  the  posterior  ridge  of  the  ilium,f 
and  in  the  course  of  the  psoas  and  glutei  muscles.  The  mischief 
may  also  commence  in  the  sacro-iliac  articulation,  and  the  sym- 
physis may  be  little  affected.  The  general  principles  of  treament 
are  the  same  as  in  the  former  case.  When  suppuration  takes 
place  about  the  sacro-iliac  articulation,  the  danger  is  greatly  in- 
creased. 

In  all  cases  of  separation,  when  the  patient  has  recovered  so  far 
as  to  be  able  to  move,  the  use  of  the  cold  bath  accelerates  the 
cure;  the  general  health  is  to  be  carefully  attended  to,  and  any  ur- 
gent symptom  supervening,  is  to  be  obviated  by  suitable  remedies. 

§   5.  DIFFERENCE  OF  THE  FEMALE   FROM  THE  MALE  PELVIS. 

[A  slight  inspection  is  sufficient  to  show  the  difference  in  form 
and  proportions,  between  the  female  and  the  male  pelvis. 

The  crista?,  as  well  as  the  anterior  and  superior  spinous  processes 
of  the  ossa  ilia,  are  farther  separated  in  the  female  pelvis,  hence 
affording  a  greater  concavity  to  the  iliac  fossae,  and  greater  capacity 
to  the  large  or  superior  pelvis.  The  two  straits  which  terminate 
the  cavity  of  the  pelvis,  differ  also  considerably  in  the  two  sexes. 
The  circumference,  or  brim  of  the  superior  strait  is  larger  and 
more  rounded  in  the  female,  the  sacro-vertebral  projection  is  less 
prominent ;  the  two  tuberosities  of  the  ischia  are  also  less  rough, 

*  In  a  case  related  by  De  la  Malle,  the  pain  did  not  appear  till  the  14th  day 
after  delivery,  and  was  felt  first  in  the  groin.  The  patient  was  unable  to  move 
the  leg,  and  had  acute  fever,  which  proved  fatal.  The  sacrum  was  found  sepa- 
rated three  lines  from  the  ilium. 

In  the  operation  of  dividing  the  pubis  in  a  parturient  woman,  it  was  found  that 
one  side  yielded  more  than  the  other,  and  consequently  that  side  would  sutler 
most  at  the  sacrum.     Baudelocque,  L'Art,  &c.  section  2063. 

f  D.  Smellie  relates  an  instance,  where,  during  labour,  the  woman  felt  violent 
pain  at  the  right  sacro-iliac  symphysis.  On  the  5th  day  this  pain  was  extremely 
severe,  and  attended  with  acute  fever;  but  the  symptoms  were  abated  by  blood- 
letting, and  a  clyster,  and  fomentations,  which  produced  a  copious  perspiration. 
She  was  not  able  to  walk  for  five  or  six  months  without  crutches,  but  was  re- 
stored to  the  use  of  the  limb,  by  means  of  the  cold  bath.  Ooll.l.  n.  i.e.  1. 


16 

less  projecting,  and  farther  separated,  than  in  the  male ;  and  finally, 
the  extremity  of  the  os  coccygis  does  not  approach  so  near  to  the 
arch  of  the  pubis,  which  affords  to  the  inferior  strait,  greater  ex- 
tent from  its  anterior  to  its  posterior  termination. 

With  regard  to  the  excavation  of  the  pelvis,  it  is  more  concave 
in  the  posterior  part  in  the  female,  because  the  sacrum  has  greater 
height  and  curvature ;  the  arch  of  the  pubis  is  broader,(c)  and  its 
branches  are  also  turned  more  outward  and  forward.  The  region 
of  die  pubis  is  less  convex,  and  the  cartilage,  which  forms  the  sym- 
physis, is  thicker  and  shorter,  offering  towards  the  interior  of  the 
pelvis  a  prominence  more  remarkable  than  in  the  male. 

But  in  this  very  conformation,  which  nature  appears  to  have  in- 
tended to  render  labour  more  easy,  there  are  certain  circumstances 
exposing  the  female  to  peculiar  inconveniences,  which  in  men  are 
more  rarely  observed;  thus  the  superior  spinous  processes  which 
anteriorly  terminate  the  cristae,  or  spine  of  the  ilium,  could  not  be 
separated  to  a  greater  distance,  without  increasing  the  length  of 
Poupart's  ligament,  forming  the  crural  arch ;  from  thence  it  fol- 
lows, that  the  intestine  and  epiploon,  finding  in  this  part  less  resist- 
ance and  a  larger  aperture,  must  more  frequently  pass  down  and 
produce  femoral  hernia. 

Again,  women  having  their  hips  farther  separated,  must  neces- 
sarily step  with  less  firmness  than  men  :  for  in  progressing,  when 
one  leg  is  elevated,  the  centre  of  gravity  of  the  body  is  less  readily 
thrown  upon  the  other,  which  rests  on  the  ground ;  from  hence 
results  a  species  of  claudication  or  vacillating  gait,  in  which  the 
trunk  and  the  inferior  extremities,  instead  of  advancing  directly  or 
in  a  straight  line,  describe  greater  or  smaller  arches  of  circles.] (dj 

(~cj  Soemmering  observes,  that  the  angle  between  the  diverging  branches  of 
the  pubis,  is  in  the  male  an  acute  one  ;  but  in  the  female  forms  an  angle  of  from 
80  to  90  degrees,  and  hence  approaches  nearer  to  the  figure  of  an  arch,  from 
which  it  receives  its  name. 

fdj  Vide  Capuron.  cours  theorique  et  practique,  &c.  Soemmering  Tabula" 
Sceleti  feminini  juncta  descriptione. 


17 

CHAP.  III. 

Of  the  soft  Parts  which  line  the  Pelvis. 
§  1.  MUSCLES. 

Various  strong,  and  large  muscles,  pass  from  the  spine  and 
pelvis  to  the  thigh  bones,  and  act  as  powerful  bands,  strengthen- 
ing, in  a  very  great  degree,  the  articulations  of  the  pelvis.  These 
it  is  not  requisite  to  describe,  but  it  will  be  useful,  briefly  to  notice 
the  soft  parts  which  line  the  pelvis,  and  which  may  be  acted  on 
by  the  child's  head  during  labour. 

1st.  When  we  remove  the  peritoneum  from  the  cavity  of  the 
pelvis,  we  first  of  all  are  led  to  observe,  that  all  the  under  portion 
of  the  os  innominatum,  and  part  of  the  sacrum,  are  covered  with 
a  layer  of  muscular  fibres,  which  arises  at  the  brim  of  the  pelvis, 
and  can  be  traced  all  the  way  down  to  the  extremity  of  the  rec- 
tum. This  is  the  levator  ani ;  it  is  a  strong  muscle,  with  many 
glossy  tendinous  fibres,  especially  at  the  fore  part,  where  it  lines 
the  ossa  pubis.  Under  the  symphysis,  it  is  pierced  by  the  urethra 
and  vagina ;  and  during  the  passage  of  the  child's  head,  those 
fibres  which  surround  the  vagina  must  be  considerably  distended ; 
and  this  is  more  readily  affected,  as  the  anus  is  brought  forwards 
when  the  perinaeum  is  distended. 

2d.  Under  this,  on  each  side,  we  have  arising  from  the  mem- 
brane that  fills  up  the  thyroid  hole,  and  also  from  the  margins  of 
the  hole  and  the  inner  surface  of  the  ischium,  the  obturator  in- 
ternus,  which  forms  at  that  part  a  soft  cushion  of  flesh,  the  fibres 
running  backwards  and  downwards,  and  terminating  in  a  tendon, 
which  passes  over  the  sacro-sciatic  notch,  running  on  it  as  on  a 
pully,  in  order  to  reach  the  root  of  the  trochanter. 

3d.  We  find  the  pyriformis  arising  from  the  under  part  of  the 
hollow  of  the  sacrum,  and  also  passing  out  at  the  notch,  to  be  in- 
serted with  the  obturator  ;  and  in  laborious  parturition,  the  injury 

4 


18 

or  pressure  which  these  muscles  sustain,  is  one  cause  of  the  unea- 
siness felt  in  moving  the  thighs. 

4th.  From  the  spine  of  the  ischium,  originates  the  coccygeus, 
which  runs  backward  to  be  inserted  into  the  side  of  the  coccyx, 
in  order  to  move  and  support  it.  This  gradually  becomes  broader, 
as  we  recede  from  its  origin,  and  is  spread  on  the  inside  of  the 
sacro-sciatic  ligament.  Thus  the  cavity  of  the  pelvis  is  lined  with 
muscular  substance,  whose  fibres  are  disposed  in  a  very  regular 
order,  and  which  are  exhibited  when  the  peritoneum  and  its  cellu- 
lar substance  are  removed. 

5th.  When  we  look  at  the  upper  part  of  the  os  innominatum, 
we  find  all  the  hollow  of  the  ilium  occupied  with  the  iliacus  inter- 
nes, the  tendon  of  which  passes  over  the  fore  part  of  the  pelvis, 
to  reach  the  trochanter  of  the  thigh.  Part  of  this  muscle  is  covered 
by  the  psoas  which  arises  from  the  lumbar  vertebrae,  and  passes 
down  by  the  side  of  the  brim  of  the  pelvis  to  go  out  with  the 
former  muscle  :  though  just  upon  the  brim,  it  does  not  encroach 
on  it,  so  as  perceptibly  to  lessen  the  cavity.  These  muscles  af- 
ford a  soft  support  to  the  intestines  and  gravid  uterus. 

§  2.  ARTERIES.feJ 

Running  parallel  with  the  inner  margin  of  the  psoas  muscle, 
and  upon  the  brim  of  the  pelvis,  along  the  posterior  half  of  the 
linea  iliopectinea,  we  have  the  iliac  artery  and  vein  ;  the  artery 
lying,  for  the  upper  half  of  its  course,  above  the  vein,  and  for  the 
under  half  on  the  outside  of  it ;  when  filled,  they,  especially  the 
vein,  encroach  a  little  on  the  brim.  About  three  inches  from  the 
symphysis,  they  quit  the  brim,  running  rather  more  outward,  over 
the  part  which  forms  the  roof  of  the  acetabulum,  and  pass  out 
with  the  psoas  muscle.  The  great  lash  of  arteries  and  veins  con- 
nected with  the  pelvis,  and  inferior  extremities,  is  placed  on  the 
sacro-iliac  junction.  The  iliac  vessels,  are  so  situated,  that  they 
escape  pressure  during  labour,  when  the  head  enters  the  cavity  of 
the  pelvis ;  but  the  hypogastric  vessels  must  be  more  or  less  com- 

(~ej  Consult  Engravings  of  the  Arteries  by  C.  Bell.  Finley's  Philadelphia 
Edition. 


19 

pressed,  according  to  the  size  or  position  of  the  head,  but  the  cir- 
culation is  never  interrupted. 

§  3.  NERVES. 

When  we  attend  to  the  nerves,  we  find,  1st.  Upon  the  ilium,  at 
least  four  branches  of  cutaneous  nerves,  traversing  the  iliac,  and 
psoas  muscles,  in  order  to  pass  out  below  Poupart's  ligament. 
The  largest  of  these  cutaneous  nerves  is  the  outermost,  which  has 
its  exit  towards  the  spine  of  the  ilium.  These  nerves,  which  sup- 
ply chiefly  the  skin  of  the  thigh,  cannot  suffer  during  labour ;  but 
sometimes  may,  from  the  position  of  the  child,  or  the  inclination 
of  the  uterus,  sustain  pressure,  during  gestation,  and  occasion 
numbness  and  anomalous  sensations  in  the  thigh.  2d.  Between 
the  two  muscles,  and  in  part  covered  by  the  outer  margin  of  the 
psoas,  is  the  anterior  crural  nerve,  which  is  formed  by  the  second, 
third,  and  fourth  lumbar  nerves.  It  is  of  considerable  size,  and 
has  a  greater  share  than  the  others,  in  producing  the  uneasy  sen- 
sations I  have  mentioned.  3d.  Running  parallel  with  the  brim  of 
the  pelvis,  but  three  quarters  of  an  inch  below  it,  in  the  cavity  of 
the  pelvis,  is  the  obturator  nerve,  coming  from  the  third  lumbar, 
and  which  may  be  traced  all  along  the  side  of  the  ilium  to  the  thy- 
roid hole.  In  many  cases,  it  cannot  fail,  during  labour,  to  be 
pressed  on  by  the  head.  4th.  Beneath  the  vessels  at  the  sacro- 
iliac junction,  we  have  the  great  nerves  which  form  the  sciatic 
nerve,  which  is  made  up  of  the  fourth  and  fifth  lumbar  nerves, 
and  the  first  sacral  nerve,  which  is  as  large  as  either  of  the  former: 
to  these  are  added  the  second  and  third  sacral,  which  are  much 
smaller.  The  fourth  lumbar  nerve  passes  down  on  the  sacro-iliac 
junction,  and  is  quite  covered  with  the  vessels.  The  fifth  tra- 
verses that  curved  part  of  the  sacrum,  which  lies  betwixt  its  pro- 
montory and  side ;  like  the  former,  it  is  hid  by  the  vessels.  In 
going  to  form  the  sciatic  nerve,  the  fourth  lumbar  nerve  passes 
under  the  gluteal  artery,  or  the  common  trunk  of  the  gluteal  and 
ischiatic  arteries,  and  the  fifth  passes  over  it.  The  first  sacral 
nerve  passes  along  the  upper  margin  of  the  pyriform  muscle,  to 
join  with  these  at  the  sacro-sciatic  notch.     There  a  large  plexus 


20 

is  formed,  which,  uniting  into  a  single  trunk,  passes  out,  and  is  the 
greatest  nerve  in  the  body.  The  lumbar  nerves  may  be  pressed 
on  early  in  labour ;  but  from  the  cushion  of  vessels  and  cellular 
substance  which  defends  them,  they  suffer  little.  When  the  head 
has  descended  lower,  and  is  beginning  to  turn,  the  first  sacral  nerve 
may  be  compressed.  Pressure  of  the  nerve  produces  pain,  numb- 
ness, and  cramp  in  the  thigh  and  leg.  Different  nerves  are  acted 
on  in  different  stages  of  labour.  In  the  very  beginning,  the  ante- 
rior crural  nerve  may  be  irritated  or  gently  compressed,  producing 
pain  in  the  fore  part  of  the  thigh  j  next  the  obturator,  producing 
pain  in  the  inside ;  and  last  of  all,  the  back  part  suffers  from  the 
pressure  on  the  ischiatic  nerve.  5th.  The  second  and  third  sacral 
nerves  are  small,  compared  to  the  first.  They  are  covered  by 
the  pyriformis  muscle,  but  part  of  them  pierce  it,  forming  a  plexus, 
which  joins  the  sciatic  nerve,  and  sends  twigs  to  the  bladder,  rec- 
tum, &c.  This  plexus  may  be  pressed  in  the  last  stage  of  labour ; 
and  the  irritation  thus  produced  may  be  one  cause  of  the  passage 
of  the  faeces,  which  generally  takes  place  involuntarily.  6th.  The 
fourth  sacral  nerve  is  altogether  devoted  to  the  extremity  of  the 
rectum,  and  its  vicinity. 

The  great  plexus,  forming  the  sciatic  nerve,  as  it  lies  in  the 
sacro-sciatic  notch,  yields  to  any  pressure  it  may  receive,  and 
cannot  suffer  in  labour,  at  least  so  as  to  cause  inconvenience  ;  but 
the  nerves  going  to  it  may  suffer,  and  the  person  not  only  have 
cramp  and  pain  during  labour,  but  palsy  and  lameness  for  a  long 
time  afterwards.  Friction,  and  the  warm  bath,  at  first,  may  relieve 
the  pain ;  and  then,  the  cold  bath  may,  with  much  advantage,  be 
employed  for  perfecting  the  cure. 

§  4.  LYMPHATICS. 

The  lymphatics  in  the  upper  part  of  the  pelvis  follow  the  course 
of  the  iliac  vessels,  forming  a  large  and  very  beautiful  plexus,  from 
Poupart's  ligament  to  the  lumbar  vertebrae.  These  are  out  of  the 
way  of  pressure  during  labour.  Numerous  glands  accompany 
them,  which  are  sometimes  enlarged  by  disease,  but  they  do  not 
interfere  with  parturition.     The  lymphatics  of  the  cavity  of  the 


21 


pelvis  have  glands  in  the  course  of  the  vagina  and  rectum :  and 
these,  if  enlarged,  may  impede  delivery. 


CHAP.  IV. 

Of  the 'Dimensions  of  the  Pelvis. 
§  1.  BRIM  AND  OUTLET. 

The  pelvis  has  been  divided  into  the  great  and  the  little,  the 
first  being  formed  by  the  expansion  of  the  ilia,  and  the  second, 
comprehending  all  that  part  which  is  called  the  cavity  of  the  pel- 
vis, and  which  lies  below  the  linea  ilio-pectinea.  The  cavity  of 
the  pelvis  is  the  part  of  the  chief  importance  in  Midwifery,  and 
consists  of  the  brim,  or  entrance,  the  cavity  itself,  and  the  outlet. 
The  brim  of  the  pelvis  has  no  regular  shape,  but  approaches 
nearer  the  oval  than  any  other.  The  short  diameter  of  this,  ex- 
tends from  the  symphysis  of  the  pubis  to  the  top  of  the  sacrum. 
This  has  been  called  the  conjugate,  or  antero-posterior  diameter, 
and  measures  four  inches.  The  lateral  diameter  measures  five 
inches  and  a  quarter ;  and  the  diagonal  diameter,  or  a  line  drawn 
ftom  the  sacro-iliac  symphysis  to  the  opposite  acetabulum, 
measures  five  inches  and  an  eighth  ;  but  as  the  psoae  muscles,  and 
iliac  vessels,  overhang  the  brim  a  very  little  at  the  side,  the  diago- 
nal diameter,  in  the  recent  subject,  appears  to  be  the  longest. 
From  the  sacro-iliac  symphysis  to  the  crest  of  the  pubis,  on  the 
same  side,  is  four  inches  an  a  half.  From  the  top  of  the  sacrum,  to 
that  part  of  the  brim  which  is  directly  above  the  foramen  thyroi- 
deura,  is  three  inches  and  a  half.  The  line,  if  drawn  to  the  ace- 
tabulum, in  place  of  the  foramen,  is  a  quarter  of  an  inch  shorter  ; 
a  line  drawn  across  the  fore  part  of  the  brim,  from  one  acetabulum 
to  another,  is  nearly  four  inches  and  a  quarter. 


22 

The  outlet  of  the  pelvis  is  not  so  regular  as  the  brim,  in  its 
shape,  even  when  the  soft  parts  remain  ;  but  it  is  somewhat  oval. 
The  long  diameter  extends  from  the  symphysis  pubis  to  the  coc- 
cyx, and  measures,  when  that  bone  is  pushed  back,  as  in  labour, 
five  inches,  but  an  inch  less  when  it  is  not.  The  transverse 
diameter,  from  the  one  tuberosity  of  the  ischium  to  the  other, 
measures  four  inches.  The  outlet  of  the  pelvis  differs  materially 
from  the  brim,  in  this  respect,  that  its  margins  are  not  all  on  the 
same  level ;  an  oval  wire  will  represent  the  brim,  but,  if  applied 
to  the  outlet,  it  must  be  curved.  The  outlet,  from  the  symphysis 
pubis  to  the  tuberosity  of  the  ischium,  is  semi-oval;  but  behind,  it 
becomes  more  irregular,  and  bends  upwards  and  backwards.  The 
arch  of  the  pubis,  or  the  fore  part  of  the  outlet,  is  four  inches 
broad  at  its  base ;  and  a  perpendicular  line,  dropped  from  its  cen- 
tre to  the  bone,  is  fully  two  inches  long.  The  top  of  die  arch  will 
permit  a  circular  body  to  come  in  contact  with  it,  whose  diameter 
is  an  inch  and  a  quarter.  The  length  of  each  limb  of  the  arch  is 
three  inches  and  a  quarter. 

§  2.  CAVITY. 

The  cavity  of  the  pelvis  is  the  next  part  to  be  attended  to ;  and 
the  most  important  observation  to  be  made,  is,  that  it  is  of  unequal 
depth.  At  the  back  part  it  measures  from  five  to  six  inches,  ac- 
cording as  the  coccyx  is  more  or  less  extended ;  at  the  side,  a 
line  drawn  from  the  brim,  to  the  tuberosity  of  the  ischium,  mea- 
sures three  inches  and  three-fourths.  At  the  fore  part,  the  depth 
of  the  symphysis  pubis  is  an  inch  and  a  half.  When  the  surface 
of  the  child's  head,  then,  is  parallel  to  the  lower  edge  of  the  sym- 
physis, the  head  is  still  far  from  having  entered  fully  into  the  cavity 
of  the  pelvis;  it  cannot  be  considered  in  the  cavity,  until  it  be 
lodged  fairly  in  the  hollow  of  the  sacrum. 

It  may  be  proper  to  notice  the  dimensions  of  different  parts  of 
the  cavity  itself.  An  oblique  line,  drawn  from  the  sacro-iliac  junc- 
tion, on  one  side,  down  to  the  opposite  tuberosity,  measures  six 
inches  ;  and  the  long  axis  of  the  child's  head,  before  it  takes  the 
turn  forwards,  corresponds  to  this  line.     From  the  ramus  of  the 


23 

ischium,  to  the  opposite  sacro-iliac  junction,  is  five  inches.  From 
the  top  of  the  arch  of  the  pubis,  or  orifice  of  the  urethra,  to  the 
second  bone  of  the  sacrum,  is  four  inches  and  five-eighths,  to  five 
inches.  A  line  drawn  from  the  top  of  the  arch  to  the  top  of  the 
sacrum,  is  about  a  quarter  of  an  inch  more  than  the  antero-poste- 
rior  diameter  of  the  brim.  From  the  top  of  the  arch  to  the  spine 
of  the  ischium,  is  three  inches  and  a  half.  From  the  tuberosity 
of  the  ischium  to  the  centre  of  the  sacrum  is  four  inches.  From 
the  back  part  of  the  tuberosity  to  the  sacro-iliac  junction  on  the 
same  side,  is  three  inches  and  a  half.  From  the  extremity  of  the 
tuberosity  to  the  spine  of  the  ischium,  is  two  inches.  From  the 
spine  to  the  sacrum  is  two  inches,  and  from  the  top  of  the  arch  of 
the  pubis  to  the  plane  of  the  ischium,  is  two  inches.  The  breadth 
of  the  plane  itself  is  two  inches  ;  so  that  a  line  traversing  these  dif- 
ferent parts,  from  the  symphysis  to  the  sacrum,  would  measure, 
including  its  slight  irregularities,  six  inches.  From  the  tuberosity 
to  the  inferior  part  of  the  thyroid  hole,  is  an  inch  and  a  half,  the 
long  diameter  of  the  sacro-sciatic  notch,  is  two  inches  and  three- 
eighths  ;  the  short,  one  inch  and  three  quarters. (f) 

In  the  living  subject,  we  can  readily  recognise  these  different 
parts  of  the  pelvis;  and  by  the  relation  which  one  bears  to  the 
rest,  we  can  ascertain,  by  careful  examination  with  the  finger,  not 
only  the  relative  position  of  the  head  with  regard  to  any  one  spot, 
and  consequently,  its  precise  situation  and  progress  in  the  pelvis, 
but  also  the  shape  and  dimensions  of  the  pelvis  itself.fgj 

CfJ  There  may  be  some  variation  in  dimensions,  as  stated  by  different 
writers ;  but  it  is  probable,  the  above  were  given  by  our  author,  from  actual 
measurement,  of  what  he  considered,  a  standard  pelvis.  A  similar  observation 
may  be  applied  to  the  dimensions  of  the  child's  head,  as  stated  in  the  succeeding 
chapter. 

CgJ  The  very  ingenious  and  indefatigable  Bichat  has  observed,  that  stature 
has  no  influence,  or  at  least  very  little,  on  the  dimensions  of  the  pelvis  ;  and 
that  the  individual  differences  which  may  occur,  are  totally  independent  of 
stature.  It  is  acknowledged,  continues  he,  that  delivery  is  as  easy  in  small  as  in 
large  women,  although  the  first  may  bring  forth  very  bulky  children,  and  who, 
indeed,  may  be  disproportioned  to  the  bulk  of  their  mother's  bodies,  if  a  com 
parison  of  size  should  be  instituted  between  the  two. 

Anatomie  Descriptive,  to',  1  p.  181—2. 


24 


§  3.  PELVIS  ABOVE  THE  BRIM, 

The  shape,  extent,  and  dimensions  of  the  great  pelvis,  or  that 
part  which  is  above  the  brim,  must  be  mentioned  likewise,  espe- 
cially as  these  are  of  importance  in  estimating  the  deformity  of  a 
pelvis.  From  the  symphysis  pubis  to  the  commencement  of  the 
iliac  wing,  at  the  inferior  spinous  process,  is  nearly  four  inches. 
From  the  inferior  spinous  process  to  the  posterior  ridge  of  the 
ilium,  a  line  subtending  the  hollow  of  the  costa,  measures  five 
inches.  The  distance  from  the  superior  spine  is  the  same.  From 
the  top  of  the  crest  of  the  ilium  to  the  brim  of  the  pelvis,  a  direct 
line  measures  three  inches  and  a  half.  The  distance  betwixt  the 
two  superior  anterior  spinous  processes  of  the  ilium,  is  fully  ten 
inches.  A  line  drawn  from  the  top  of  the  crest  of  the  ilium  to  the 
opposite  side,  measures  rather  more  than  eleven  inches,  and 
touches  in  its  course  the  intervertebral  substance  betwixt  the  fourth 
and  fifth  lumbar  vertebrae.  A  line  drawn  from  the  centre  of  the 
third  lumbar  vertebra,  counting  from  the  sacrum  to  the  upper  spine 
of  the  ilium,  measures  six  inches  and  three  quarters.  A  line  drawn 
from  the  same  vertebra  to  the  top  of  the  symphysis,  measures 
seven  inches  and  three  quarters,  and,  when  the  subject  is  erect, 
this  line  is  exactly  perpendicular. 

To  conclude  my  observations  on  the  dimensions  of  the  pelvis,  I 
remark,  that  the  shape  is  different  in  the  child  and  the  adult.  The 
dimensions  of  the  brim  are  reversed  in  these  two  states :  the  Ions: 
diameter  of  the  foetal  pelvis,  extending  from  the  pubis  to  the  sa- 
crum. By  slow  degrees,  the  shape  changes;  and  nearly  about  the 
time  of  puberty,  the  conjugate  and  lateral  diameters  are  equal. 
When  the  female  is  fully  perfected,  the  brim  becomes  more  oval, 
the  long  diameter  extending  from  one  side  to  the  other.  If  a  girl 
should,  very  early,  become  a  mother,  the  shape  of  the  pelvis  may 
occasion  a  painful  and  tedious  lahpur.(A) 

(/<)  This  remarkable  difference  in  the  comparative  dimensions  of  the  female 
pelvis  before  and  after  puberty,  has  been  pointed  out  by  analogy,  and  observed 
among  the  females  of  quadrupeds  whose  pelvis  does  not  complete  its  deve- 
lopement,  nor  acquire  the  form  and  proportions  necessary  for  the  expulsion  of 
the  fostus  until  the  period  of  puberty.     Vid.  Capuron. 


25 


§  4.  AXIS  OF  THE  BRIM  AND  OUTLET. 

Finally,  we  are  to  remember  that  the  brim,  and  the  outlet  of  the 
pelvis,  are  not  parallel  to  each  other,  but  placed  at  a  considerable 
angle.  The  axis  of  the  brim  will  be  represented  by  a  line  drawn 
from  near  the  umbilicus,  downwards  and  backwards,  to  the  coccyx; 
that  of  the  outlet,  by  a  line  drawn  from  the  orifice  of  the  vagina  to 
the  first  bone  of  the  sacrum.  The  precise  points,  however,  which 
these  lines  will  touch,  must  vary  a  little,  according  to  the  conforma- 
tion and  obliquity  of  the  pelvis,  and  the  prominence  of  the  abdomen. 
Each  different  part  of  the  cavity  of  the  pelvis  has  its  own  proper 
axis,  and  the  line  of  motion  of  the  child's  head  must  always  cor- 
respond to  the  axis  of  that  part  of  the  pelvis  in  which  it  is  placed. 
A  pretty  good  idea  of  this  subject  with  regard  to  labour  may  be 
obtained  by  placing  a  small  catheter,  of  the  usual  curvature,  in  the 
axis  of  the  brim,  and  making  its  extremity  pass  out  at  the  axis  of 
the  outlet. 


CHAP.  V. 

Of  the  Head  of  the  Child,  and  its  progress  through  the  Pelvis 

in  Labour. 

§  1.  BONES  OF  THE  HEAD. 

The  head  of  the  child  is  made  up  of  many  different  bones,  and 
those  of  the  cranium  are  very  loosely  connected  together  with 
membrane.  The  frontal,  temporal,  parietal,  and  occipital  bones, 
compose  the  bulging  part  of  the  cranium  and  their  particular  shape 
regulates  the  direction  of  the  sutures.  The  occipital  bone  is  con- 
nected to  the  parietal  bones,  by  the  lambdoidal  suture,  which  is 
readily  discovered  through  the  integuments,  by  its  angular  direc- 
tion. The  parietal  bones  are  joined  to  the  frontal  bone,  by  the 
coronal  suture,  which  is  distinguished  by  its  running  directly 
across  the  head,  and  they  are  connected  to  each  other  by  the  sa4- 

a 


26 

gital  suture,  which  runs  in  a  direct  line  from  the  occipital,  to  the 
frontal  bone ;  as  the  os  frontis,  in  the  foetus,  consists  of  two  pieces, 
it  can  sometimes  be  easily  traced  with  the  ringer,  even  to  the  nose. 
Let  the  sagital  suture  be  divided  into  three  equal  parts.  From  the 
middle  one  which  I  call  the  central  portion,  a  line  or  band  may  be 
drawn  to  the  lateral  part  of  the  lower  jaw,  and  which  will  traverse 
the  parietal  protuberance,  and  the  external  ear.  As  this,  in  labour, 
is  parallel  to  the  axis  of  the  brim  of  the  pelvis,  until  the  head 
makes  its  turn,  I  call  it  the  line  of  axis.  The  upper  and  ante- 
rior angles  of  the  parietal  bones,  and  the  corresponding  corners  of 
the  two  pieces  of  the  frontal  bone,  are  rounded  off,  so  as  to  leave  a 
quadrangular  vacancy,  which  is  filled  up  with  tough  membrane. 
This  is  called  the  great,  or  anterior  fontanell,  to  distinguish  it  from 
another  smaller  vacancy  at  the  posterior  extremity  of  the  sagital 
suture,  which  is  called  the  small  fontanell.  The  first  is  known  by 
its  four  corners,  and  by  its  extending  forward  a  little  betwixt  the 
frontal  bones,  and  whenever  it  is  felt,  in  an  examination,  we  may 
expect  a  tedious  labour;  for  the  head  does  not  lie  in  the  most  fa- 
vourable position.  The  little  fontanell  cannot,  during  labour,  be 
perfectly  traced,  as  it  is  lost  in  the  angular  lines  of  the  lambdoidal 
suture,  which,  however,  ought  to  be  readily  discovered.  The  head 
is  of  an  oblong  shape,  and  its  anterior  extremity  at  the  temples  is 
narrower  than  the  posterior,  which  bulges  out  at  the  sides  by  a  ris- 
ing of  the  parietal  bones,  called  the  parietal  protuberances :  from 
these  the  bones  slope  backwards,  like  an  obtuse  angle,  to  the  upper 
part  of  the  occiput,  which  is  a  little  flattened,  and  is  called  the 
vertex.  The  general  shape  of  the  back  part  is  hemispherical. 
From  these  protuberances,  the  head  also  slopes  downwards  and 
forwards  to  the  zygomatic  process  of  the  temporal  bone,  becoming, 
at  the  same  time,  gradually  narrower. 

§  2.  SIZE  OF  THE  HEAD. 

The  longest  diameter  of  the  head  is  from  the  vertex  to  the  chin, 
and  this  is  near  five  inches.fi)     From  the  root  of  the  nose  to  the 

(?)  This  is  termed  the  oblique  diameter,  to  distinguish  it  from  the  next. 
When  the  vertex  is  stretched  out  in  laborious  births,  it  is  sometimes  extended  to 
six  or  seven  inches. 


%1 

vertex,  [which  is  called  the  long  diameter,]  and  from  the  chin  to 
the  central  portion  of  the  sagital  suture,  measures  four  inches. 
From  the  one  parietal  protuberance  to  the  other,  [which  is  called 
the  transverse  diameter,]  a  transverse  line  measures  from  three 
inches  and  a  quarter,  to  three  inches  and  a  half.  From  the  nape 
of  the  neck  to  the  crown  of  the  head,  is  three  inches  and  a  half, 
[and  is  called  the  perpendicular  diameter.]  From  the  one  temple 
to  the  other  is  two  inches  and  a  half.  From  the  occiput  to  the  chin, 
along  the  base  of  the  cranium,  is  four  inches  and  a  half.  From 
one  mastoid  process  to  the  other,  along  the  base,  is  about  two 
inches ;  from  cheek  to  cheek  is  three  inches.  Although  these  may- 
be the  average  dimensions  of  the  head,  yet,  owing  to  the  nature  of 
the  sutures,  they  may  be  diminished,  and  the  shape  of  the  head  al- 
tered. The  one  bone  may  be  pushed  a  little  way  under  the  other, 
and,  by  pressure,  the  length  of  the  head  may  be  considerably  in- 
creased, whilst  its  breadth  is  diminished ;  but  these  two  alterations 
by  no  means  correspond,  in  a  regular  degree,  to  each  other. 

The  size  of  the  male  head  is  generally  greater  than  that  of  the 
female.  Dr.  Joseph  Clarke,*  an  excellent  practitioner,  upon 
whose  accuracy  I  am  disposed  fully  to  rely,  says,  that  it  is  a 
twenty-eighth  or  thirtieth  part  larger.  It  is  a  well  established  fact, 
that  owing  to  the  greater  size  of  male  children,  women  who  have 
the  pelvis  in  any  measure  contracted,  have  often  a  more  tedious 
labour,  when  they  bear  sons  than  daughters  ;  and  many  who  have 
the  pelvis  well  formed,  suffer  from  the  effects  on  the  soft  parts. 
Dr.  Clarke  supposes,  that  one-half  more  males  than  females  are 
born  dead,  owing  to  tedious  labour,  or  increased  pressure  on  the 
brain;  and  owing  to  these  causes,  a  greater  number  of  males  than 
females  die,  soon" after  birth.  In  twin  cases,  again,  as  the  chil- 
dren are  smaller,  he  calculates  that  only  one-fifth  more  males  than 
females  are  still-born.  Dr.  Blandf  says,  that  out  of  eighty-four 
still-born  children,  forty-nine  were  males,  and  thirty-five,  females. 


*  Phil.  Trans.  Vol.  LXXVt. 
1  Phil.  Trans.  Vol.  LXXJ. 


28 


§  3.   PASSAGE  OF   THE   HEAD. 

By  comparing  the  size  of  the  head  with  the  capacity  of  the  pel- 
vis, it  is  evident  that  the  one  can  easily  pass  through  the  other. 
But  I  apprehend  that  the  comparison  is  not  always  correctly  made, 
for  the  child  does  not  pass  with  the  long  diameter  of  its  cranium 
parallel  to  a  line  drawn  in  the  direction  of  the  long  diameter  of  the 
brim  of  the  pelvis ;  but  it  descends  obliquely,  so  that  less  room  is 
required.  The  central  portion  of  the  sagital  suture  passes  first,  the 
chin  being  placed  on  the  breast  of  the  child.  Now,  the  length  of 
a  line  drawn  from  the  nape  of  the  neck,  to  the  crown  of  the  head, 
is  three  inches  and  a  half;  a  line  intersecting  this,  drawn  from  the 
one  parietal  protuberance  to  the  other,  measures  no  more.  We 
have,  therefore,  when  the  head  passes  in  natural  labour,  a  circular 
body  going  through  the  brim,  whose  diameter  is  not  above  three 
inches  and  a  half;  and  therefore,  no  obstacle  or  difficulty  can  arise 
from  the  size  of  the  pelvis.  There  is  so  much  space  superabound- 
ing  betwixt  the  pubis  and  sacrum,  as  to  prevent  all  risk  of  injury 
from  pressure  on  the  bladder,  urethra,  or  rectum;  and  as  the  long 
diameter  of  the  head  is  descending  obliquely,  the  sides  of  the  brim 
of  the  pelvis  are  not  pressed  on.  This  is  so  certainly  the  case, 
that  the  head  may,  and  actually  often  does  pass,  without  any  great 
additional  pain  or  difficulty,  although  the  capacity  of  the  pelvis  be 
a  little  contracted.  But  when  the  shoulders,  which  measure  five 
inches  across,  come  to  pass,  then  the  brim  is  completely  occupied. 
If,  however,  any  contraction  should  take  place  in  the  lateral  diam- 
eter, the  child  would  still  pass,  the  one  shoulder  descending  ob- 
liquely before  the  other. 

It  is  of  great  consequence  to  understand  the  passage  of  the  child's 
head  in  natural  labour :  for  upon  this  depends  our  knowledge  of 
the  treatment  of  difficult  labour.  The  head  naturally  is  placed 
with  the  vertex  directed  to  one  side,  or  a  little  towards  the  aceta- 
bulum, and  the  forehead,  owing  chiefly  to  the  action  of  the  pro- 
montory of  the  sacrum,  is  turned  in  the  same  degree  towards  the 
opposite  sacro-iliac  junction.  When  labour  begins,  and  the  head 
comes  to  descend,  the  chin  is  laid  on  the  sternum,  and  the  central 


29 

portion  of  the  sagital  suture  is  directed  downwards,  nearly  in  the 
axis  of  the  brim  of  the  pelvis.  When,  by  the  contraction  of  the 
uterus,  the  head  is  forced  a  little  lower,  its  apex  comes  to  touch 
the  plane  of  the  ischium.  Upon  this  the  posterior  sloping  part  of 
the  parietal  bone  slides  downwards  and  forwards,  as  on  an  inclined 
plane,  the  head  being  turned  gradually,  so  that,  in  a  little  time,  the 
face  is  thrown  into  the  hollow  of  the  sacrum,*  and  the  vertex  pre- 
sents at  the  orifice  of  the  vagina.  This  is  not  fully  accomplished, 
till  the  cranium  has  got  entirely  into  the  cavity  of  the  pelvis.  As 
the  basin  is  shallow  at  the  pubis,  the  head  is  felt  near  the  orifice  of 
the  vagina,  and  even  touching  the  labia  and  perineum,  before  the 
turn  is  completed,  and  when  the  ear  is  still  at  the  pubis.  The 
whole  of  the  cavity  of  the  pelvis,  is  so  constructed,  as  to  contribute 
to  this  turn,  which  is  further  assisted  by  the  curve  of  the  vagina, 
and  the  action  of  the  lower  part  of  the  uterus,  on  the  head  of  the 
child.  The  head,  whilst  its  long  diameter  lies  transversely,  con- 
tinues to  descend  in  the  axis  of  the  brim  of  the  pelvis ;  but  when 
it  is  turned,  it  passes  in  the  axis  of  the  outlet.  When  the  turn  is 
making,  the  direction  of  the  motion  is  in  some  intermediate  point; 
and  this  fact  should,  in  operating  with  instruments,  be  studied  and 
remembered.  When  the  pelvis  is  narrow  above,  and  the  sacrum 
projects  forward,  the  hemispherical  part  of  the  head  is  long  of 
reaching  the  inclined  plane  of  the  ischium;  and  when  the  head  is 
lengthened  out,  so  as  to  come  in  contact  with  it,  we  find,  that  al- 
though the  projection  of  the  sacrum  directs  the  vertex  sometimes 
prematurely  a  little  forward,  yet,  the  tendency  to  turn  fully,  is  re- 
sisted by  the  situation  of  the  bones  above ;  a  great  part  of  the 
cranium,  and  all  the  face,  being  above  the  brim,  and  perhaps  in 
part  locked  in  the  pelvis.  By  a  continuation  of  the  force,  the 
shape  of  the  head  may  be  altered ;  even  the  vertex  may  be  turned 
a  little  to  one  side,  its  apex  not  corresponding  exactly  to  the 
extremity  of  the  long  diameter  of  the  head ;  the  integuments 
may  be  tumefied,  and  a  bloody  serum  be  effused  between  them, 
so  as   greatly  to  disfigure  the  presentation.      As,  therefore,  in 

*  Dr.  Osborn  attributes  this  turn  to  the  action  of  the  spines  of  the  ischia  on 
the  two  parietal  bones,  but  not  on  opposite  spots. 


30 

tedious  labour,  occasioned  by  a  deformed  pelvis,  the  skull  may 
be  much  lengthened  and  misshapen,  we  are  not  to  judge  of  the 
situation  of  the  head,  by  the  position  of  the  apex  of  the  tumour 
which  it  forms  ;  but  we  must  feel  for  the  ear,  which  bears  a  steady 
relation  to  that  part  of  the  head  which  presents  the  obstacle.  The 
back  and  upper  part  of  the  head  are  compressible,  but  the  base  of 
the  skull  and  the  face  are  firm.  A  line  drawn  from  the  neck  to 
the  forehead,  passing  over  the  ear,  is  to  be  considered  as  the  boun- 
dary betwixt  these  parts  of  opposite  character ;  and  therefore  we 
attend  to  the  relative  situation  of  the  ear,  as  it  ascertains  both  the 
position  of  the  head,  and  its  advancement  through  the  brim. 


CHAP.  VI. 

Of  Diminished  Capacity,  and  Deformity  of  the  Pelvis. 
§   1.  DEFORMITY  FROM  RICKETS. 

The  pelvis  may  have  its  capacity  reduced  below  the  natural 
standard  in  different  ways.  It  may  be  altogether  upon  a  small 
scale,  owing  to  the  expansion  stopping  prematurely,  the  different 
bones,  however,  being  well-formed,  and  correct  in  their  relative 
proportions  and  distances.  This  may  occasion  painful  labour,  but 
rarely  causes  such  difficulty  as  to  require  the  use  of  instruments. 
Sometimes  the  bones  are  all  of  their  proper  size,  but  the  sacrum  is 
perfectly  straight,  by  which,  although  both  the  brim  and  outlet  are 
sufficiently  large,  yet  the  cavity  of  the  pelvis  is  lessened ;  or  when 
all  the  other  parts  are  natural,  the  spines  of  the  ischium  may  be 
exuberant,  encroaching  on  the  lower  part  of  the  pelvis. 

Another  cause  of  diminished  capacity  is  the  disease  called 
rickets,  in  which  the  bones  in  infancy  are  defective  in  their 
strength,  the  proportion  of  earthy  matter  entering  into  their  com- 
position being  too  small.  In  this  disease,  the  long  bones  bend, 
and  their  extremities  swell  out ;  the  pelvis  becomes  deformed,  the 
back  part  approaching  nearer  to  the  front,  and  the  relative  distance 


at 

of  the  parts  being  lost.  The  distortion  may  exist  in  various  de- 
grees. Sometimes  the  promontory  of  the  sacrum  only  projects 
forward  a  very  little  more  than  usual,  or  is  directed  more  to  one 
side  than  the  other  ;*  and  the  curvature  of  the  bone  may  be  either 
increased  or  diminished.  If  the  sacrum  project  only  a  little,  with- 
out any  other  change,  the  capacity  of  the  brim  alone  is  diminished: 
but  if  the  curvature  be  at  the  same  time  smaller  than  usual,  the 
cavity  of  the  pelvis  is  lessened  :  but  unless  the  ischia  approach 
nearer  together,  or  the  lower  part  of  the  sacrum  be  bent  forward, 
the  outlet  is  unaffected ;  and  in  most  cases  of  moderate  deformity 
the  outlet  is  not  materially  changed.  In  greater  degrees  of  the  dis- 
ease, the  anterior  part  of  the  brim  becomes  more  flattened,  the 
linea  ilio-pectinea  forming  a  small  segment  of  a  pretty  large  circle. 
The  sacrum  forms  part  of  a  concentric  circle  behind;  and  thus  the 
brim  of  the  pelvis,  instead  of  being  somewhat  oval,  is  rendered  se- 
micircular or  crescentic,  and  its  short  diameter  is  sometimes  re- 
duced under  two  inches.  The  promontory  of  the  sacrum  may 
either  correspond  to  the  symphysis  pubis,  or  may  be  directed  tof 

*  It  is  not  necessary  to  give  examples  of  every  degree  of  deformity  ;  but  it  will 
be  useful  to  select  some  specimens  of  the  different  kinds.  The  slighter  degrees 
do  not  require  to  be  particularized.  I  shall  first  of  all  give  the  dimensions  of  a 
dried  pelvis,  so  contracted,  as  to  prevent  a  child  at  the  full  time  from  passing 
without  assistance.  From  the  pubis  to  the  sacrum,  it  measures  three  inches; 
from  the  acetabulum  to  the  sacrum,  on  the  right  side,  two  and  a  half  inches  ;  on 
the  left,  two  inches  and  seven-eighths;  from  the  brim  above  the  foramen  thyroi- 
deum,  to  the  opposite  sacro-iliac  junction,  five  inches ;  from  the  same  part  of  the 
brim  on  one  side,  to  the  same  on  the  opposite,  three  inches  and  a  half;  trans- 
verse diameter,  four  inches  and  seven-eighths;  from  the  arch  of  the  pubis  to  the 
hollow  of  the  sacrum,  five  inches ;  from  one  tuberosity  of  the  ischium  to  the 
other,  four  inches  and  a  half;  from  one  spine  to  another,  four  inches  and  a  half; 
the  arch  of  the  pubis  is  natural.  The  distance  from  the  face  of  the  third  lumbar 
vertebra,  to  the  spine  of  the  ilium  on  both  sides,  is  six  inches.  These  dimensions 
may  be  compared  with  those  of  the  well-formed  pelvis.  The  symphysis  pubis 
has  the  cartilage  in  the  inside,  projecting  like  a  spine,  which  added  to  the  small- 
ness  of  the  pelvis  when  recent.  The  linea  ilio-pectinea  also,  on  the  left  side,  is 
for  the  length  of  two  inches  as  sharp  as  a  knife  ;  and  from  these  two  causes,  the 
cervix  uteri  and  bladder  were  torn  in  labour. 

t  In  a  pelvis  of  this  kind,  which  I  shall  describe,  the  vertebrae  and  sacrum  lean 
much  to  the  left  side.  The  line  from  the  promontory  of  the  sacrum  to  the  part 
of  the  pubis  opposite  it,  is  barely  an  inch  and  a  half;  but  an  oblique  line  draw?' 


32 

one  side,  rendering  the  shape  of  the  brim  more  irregular  and  the 
dimensions  smaller  on  one  side  than  the  other.  In  some  instances, 
the  shape  of  the  brim  is  like  an  equilateral  triangle ;  and  although 
the  diameter  from  the  pubis  to  the  sacrum  be  not  diminished,  yet 
the  acetabula  being  nearer  the  sacrum,  the  passage  of  the  head  is 
obstructed. 

§.  2.  DEFORMITY  FROM  MALACOSTEON. 

The  pelvis  is  likewise,  especially  in  manufacturing  towns,  some- 
times distorted  by  malacosteon,  or  softening  of  the  bones  of  the 
adult.  This  is  a  disease  which  sometimes  begins  soon  after  de- 
livery, and  very  frequently  during  pregnancy.  It  is,  indeed,  com- 
paratively rare  in  those  who  do  not  bear  children,  and  it  is  always 
increased. in  its  progress  by  gestation.  It  must  be  carefully  at- 
tended to,  for,  to  a  negligent  practitioner,  it  has  at  first  very  much 
the  appearance  of  chronic  rheumatism.  It  generally  begins  with 
pains  about  the  back,  and  region  of  the  pelvis.  These  pains  are 
almost  constant,  or  have  little  remission.  They  are  attended  with 
increasing  lameness,  loss  of  flesh,  weakness,  and  fever ;  but  the 
distinguishing  mark  is  diminution  of  stature,  the  person  gradually 
becoming  decrepid.  In  malacosteon  the  pelvis  suffers,  but  the 
distortion  is  generally  different  from  that  produced  by  rickets;  for 
whilst  the  top  of  the  sacrum  sometimes  sinks  lower  in  the  pelvis, 

to  the  symphysis,  which  is  to  the  right  of  the  promontory,  is  near  two  inches. 
From  the  promontory  to  the  side  of  the  brim  at  the  ilium  on  the  left  side,  is  two 
inches  and  three-tenths ;  on  the  right  side,  three  inches  and  four-tenths.  On 
the  left  side,  from  the  lateral  part  of  the  sacrum  to  the  acetabulum,  is  nine-tenths 
of  an  inch  ;  on  the  right  side,  fully  two  inches.  Now  in  this  pelvis,  when  the 
soft  parts  are  added,  we  shall  find  that  an  oval  body  may  pass  on  the  right  side, 
whose  long  diameter  is  three  inches  and  a  half,  and  whose  short  diameter  is 
barely  two  inches. 

In  a  pelvis  with  a  semicircular  brim,  whose  short  diameter,  at  the  middle  and 
each  side,  is  one  inch  and  a  half,  an  oval  could  pass  when  the  soft  parts  are  added, 
whose  long  diameter  is  about  two  inches  and  a  quarter;  and  the  short  one  about 
one  inch  and  a  quarter. 


33 

and  always  is  pressed  forward,*  the  acetabula  are  pushed  back- 
wards and  inwards  towards  the  sacrum  and  towards  each  other  ;f 
so  that,  were  it  compatible  with  life,  for  the  disease  to  last  so  long, 
these  parts  would  meet  in  a  common  point,  and  close  up  the  pel- 
vis, or  at  least  convert  its  cavity  to  three  slits.  The  ossa  pubis 
form  a  very  acute  angle ;  so  that  the  brim  of  the  pelvis,  instead  of 
being  a  little  irregular  as  in  slight  cases  of  rickets,  or  semicircular 
as  in  the  greatest  degree  of  that  disease,  consists,  when  malacos- 

*  In  a  well-formed  pelvis,  a  line  drawn  transversely  along  the  brim,  and  in  con- 
tact with  the  sacrum,  either  touches  at  its  two  extremities,  the  sacro-iliac  junc- 
tions or  the  linea  ilio-pectinea,  about  half  an  inch  before  them  ;  but  in  a  very 
deformed  pelvis,  such  a  line  will  touch  the  brim,  at,  or  even  before  the  aceta- 
bula. In  a  well-formed  pelvis,  a  line  drawn  from  the  middle  of  the  linea  ilio- 
pectinea  on  one  side,  to  the  same  spot  on  the  opposite  side,  is  about  an  inch,  or 
an  inch  and  a  half  distant  from  the  sacrum.  But  in  a  deformed  pelvis,  this  line 
would  either  pass  through  the  sacrum,  or  altogether  behind  it. 

■j-  The  following  are  the  dimensions  of  a  pelvis  of  this  kind,  which  I  select  as 
a  specimen.  From  the  spinous  process  of  the  ilium  on  one  side  to  the  other,  is 
eight  inches  and  three-fourths.  From  the  lumbar  vertebrae  to  the  spinous  pro- 
cess of  the  ilium  on  the  right  side,  six  inches;  on  the  leftside,  one  inch  and 
seven-eighths.  From  the  spinous  process  of  the  ilium  back  to  its  ridge,  two 
inches  and  a  half  From  the  symphysis  pubis  to  the  sacrum,  one  inch  and  three- 
fourths.  From  the  right  acetabulum  to  the  sacrum,  six-tenths  of  an  inch ;  from 
the  left,  seven-eighths  of  an  inch.  From  the  brim  above  the  foramen  thyroideum 
to  the  same  point  on  the  opposite  side,  seven-eighths  of  an  inch.  From  the 
same  part  of  the  brim  to  the  opposite  sacro-iliac  junction,  three  inches  and  a 
half  on  both  sides.  From  the  tuberosity  of  one  ischium  to  that  of  the  other,  two 
inches  and  a  half.  From  the  tuberosity  to  the  coccyx,  three  inches.  From  the 
spine  of  one  ischium  to  that  of  the  other,  three  inches  and  a  half.  From  the 
lower  part  of  the  symphysis  pubis  to  the  hollow  of  the  sacrum,  four  inches  ;  dis- 
tance of  the  rami  of  the  pubis,  five-eighths  of  an  inch. 

This  pelvis  has  a  triangular  brim  ;  for  it  will  be  observed,  that  the  brim  above 
the  foramen  thyroideum  measures  nearly  an  inch  across,  and  therefore  there  is 
a  considerable  space  betwixt  the  two  ossa  pubis,  gradually,  however,  becoming 
narrower  toward  the  junction  of  the  bones  ;  but  little  advantage  in  delivery  can 
be  gained  from  this.  When  we  examine  it  with  a  view  to  determine  what  bulk 
may  be  brought  through  the  brim,  we  find  that  it  is  by  its  shape  virtually  divided 
into  two  cavities,  one  on  the  right,  and  the  other  on  the  left  side,  and  the  short 
diameter  of  the  one  is  six-tenths  of  an  inch,  and  that  of  the  other  seven-eighths 
of  an  inch ;  therefore  no  art  can  bring  a  child  at  the  full  time  through  it. 

In  this  pelvis,  the  sacrum  has  fallen  so  forward  at  the  top.  that  in  a  standing 
posture  the  face  of  that  bone  is  almost  horizontal,  and  its  under  part  with  the 
coccyx  is  bent  forward  like  a  hook.    The  vertebrae  are  much  distorted. 

6 


34 

teon  has  continued  long,  of  two  oblong  spaces  on  each  side  of  the 
sacrum,  terminating  before,  in  a  narrow  slit,  formed  betwixt  the 
ossa  pubis.*  In  this  narrow  space,  when  the  woman  is  advanced 
in  her  pregnancy,  the  urethra  lies,  and  the  bladder  rests  upon  the 
pendulous  belly;  so  that,  if  it  be  necessary  to  pass  the  catheter, 
we  must  sometimes  use  one  made  of  elastic  materials,  or  a  male 
catheter,  directing  the  concavity  of  the  instrument  towards  the 
pubis.  If  the  instrument  be  large,  and  the  ossa  pubis  very  near 
each  other,  it  may  be  jammed  betwixt  them,  if  it  be  incautiously 
introduced.  In  this  disease,  as  well  as  in  rickets,  it  is  to  be  re- 
membered, that  the  promontory  of  the  sacrum  may  overhang  the 
contracted  brim,  so  as  more  effectually  to  prevent  the  head  from 
entering  it. 

Rickets  being  a  disease,  which  is  at  its  greatest  height  in  infancy, 
we  have  not  at  present  to  consider  the  treatment.  Malacosteon  is, 
on  the  contrary,  a  disease  of  the  adult ;  and  it  would  be  of  great 
importance  to  child-bearing  women,  to  know  how  to  check  its  pro- 
gress. But  the  means  capable  of  doing  this  with  any  tolerable 
degree  of  certainty,  have  not  yet  been  discovered.  As  gestation 
uniformly  increases  the  disease,  it  is  proper  that  the  woman  should 
live  absque  marito.  As  there  is  evidently  a  deficiency  of  earth  in 
the  bones,  it  has  been  proposed  to  give  the  patient  phosphate  of 
lime,  but  little  advantage  has  been  derived  from  it ;  and  indeed, 
unless  we  can  change  the  action  of  the  vessels,  it  can  do  no  good 
to  prescribe  any  of  the  component  parts  of  bone.  We  have,  in  the 
present  state  of  our  knowledge,  no  means  of  rendering  the  action 
more  perfect,  otherwise  dian  by  endeavouring  to  improve  the 
general  health  and  vigour  of  the  system,  by  the  use  of  tonics,  the 

*  This  is  the  case  in  a  pelvis  where  the  distance  from  the  part  of  the  brim 
above  the  foramen  thyroideum  on  one  side,  across  to  the  same  part  on  the  op- 
posite side,  is  only  five-eighths  of  an  inch.  From  the  right  acetabulum  to  the  sa- 
crum is  an  inch  and  three-eighths.  From  the  left  is  one  inch.  This  pelvis  at  the 
brim  is  externally  triangular,  but  it  is  from  the  near  approximation  of  the  bones, 
virtually  semicircular,  the  space  betwixt  the  two  ossa  pubis  being  so  trifling  as  not 
to  merit  consideration  ;  and  the  diameter  of  the  brim  here  is  one  inch,  exclusive 
of  the  small  slit  betwixt  the  bones.  The  sacrum  in  this  pelvis  is  very  much 
curved,  and  the  outlet  is  small. 


35 

cold  bath,  and  attending  to  the  state  of  the  bowels.     Anodyne 
frictions,  and  small  blisters,  sometimes  relieve  the  pain.^^J 

§  3.  DEFORMITY  FROM  EXOSTOSIS  AND  TUMOURS. 

The  pelvis  may  be  well  formed  externally,  and  yet  its  capacity 
may  be  diminished  within,  by  exostosis  from  some  of  the  bones; 
or  it  may  be  affected  in  consequence  of  the  fracture  of  the  aceta- 
bulum, from  which  I  have  seen  extensive  and  pointed  ossifications 
stretch  for  nearly  two  inches  into  the  pelvis ;  or  steatomatous  or 
schirrous  tumours  may  form  in  the  pelvis,  being  attached  to  the 
bones  or  ligaments,  of  which  I  have  known  examples.f  An  en- 
larged ovarium,J  or  vaginal  hernia,^  may  also  obstruct  delivery, 

*  Upon  the  subject  of  deformity  of  the  pelvis,  and  for  tables  of  many  particular 
instances  of  distortion,  I  have  great  pleasure  in  referring  the  reader  to  the  works 
of  Dr.  Hull,  a  practitioner  of  sound  judgment,  and  extensive  knowledge. 

fkj  Deformity  of  the  pelvis,  from  the  above  causes,  may  be  considered  as 
comparatively  a  rare  disease  in  the  United  States.  In  the  course  of  my  obstetri- 
cal practice,  1  can  at  present  recollect  very  few  cases,  where  embryulcia  and  the 
employment  of  the  crotchet  became  indispensably  necessary  ;  and  what  may  be 
•worthy  of  remark,  these  were  in  individuals  natives  of  Europe,  chiefly  of  Ireland. 
A  deformed  pelvis  is  scarcely  known  among  the  aborigines  of  our  country.  This 
subject  shall  again  be  taken  up  when  embryulcia  is  treated  of;  an  operation, 
which  we  fear,  is  frequently  resorted  to  very  unnecessarily  at  least,  to  make  use 
of  the  mildest  term. 

\  Dr.  Denman  mentions  a  fatal  case  of  this  kind,  to  which  Dr.  Hunter  was  called. 
The  child  was  delivered  by  the  crotchet,  but  the  patient  died  on  the  fourth  day. 
A  firm  fatty  excrescence,  springing  from  one  side  of  the  sacrum  was  found  to 
have  occasioned  the  difficulty.  Vide  lntrod.  Vol.  II.  p.  72. — Baudelocque,  in  the 
5th  vol.  of  Recueil  Periodique,  relates  a  case,  where,  in  consequence  of  a  schir- 
rous tumour  adhering  to  the  pelvis  the  crotchet  was  necessary.  In  a  subsequent 
labour,  the  cesarean  operation  was  performed,  and  proved  fatal  to  the  mother. — 
Dr.  Drew  records  an  instance  where  the  tumour  adhered  to  the  sacro-sciatic  liga- 
ment, and  was  successfully  extirpated  during  labour.  It  was  14  inches  in  cir- 
cumference.    Vide  Edin.  Journal,  Vol.  I.  p.  23. 

+  A  fatal  case  of  this  kind  occurred  to  Dr.  Ford,  and  is  noticed  by  Dr.  Den- 
man. Another  fatal  instance  is  recorded  by  M.  Baudelocque,  L'Art,  section 
1964.  See  also  a  case  by  Dr.  Merriman,  Med.  and  Chir.  Trans.  LI.  47.  This 
ovarium  contained  a  fluid,  and  probably  might  have  been  opened  during  labour 
with  advantage. 

§  Several  cases  of  this  kind  have  been  met  with,  and  in  one  related  by  M. 
Brand,  and  noticed  by  Dv.  Sandifort  in  his  Obs.  Anat.  Path,  the  woman  died 
undelivered. 


36 

even  so  much  as  to  require  the  crotchet;  and  therefore,  although 
they  be  not  indeed  instances  of  deformed  pelvis,  yet  as  they  di- 
minish the  capacity  of  the  cavity,  as  certainly  as  any  of  the  former 
causes  which  I  have  mentioned,  it  is  proper  to  notice  them  at  this 
time.*  Enlarged  glands  in  the  course  of  the  vagina,  polypous  ex- 
crescences about  the  os  uteri  or  vagina,  schirrus  of  the  rectum, 
and  firm  encysted  tumours  in  the  pelvis,  may  likewise  afford  an 
obstacle  to  the  passage  of  the  child.  Some  tumours,  however, 
gradually  yield  to  pressure,  and  disappear  until  the  child  be  born ; 
others  burst,  and  have  their  contents  effused  in  the  cellular  sub- 
stance. A  large  stone  in  the  bladder  may  also  be  so  situated  dur- 
ing labour,  as  to  diminish  very  much  the  cavity  of  the  pelvis;  and 
it  may  be  even  necessary  to  extract  the  stone  before  the  child  be 
delivered. 

Tumours  in  the  pelvis  are  produced  either  by  enlargement  of 
some  of  its  contents,  as  for  instance  the  ovarium  or  glands  ;  or,  by 
new  formed  substances.  The  ovarian  kind  are  often  moveable, 
the  other  generally  fixed;  and  they  may  consist  of  fatty,  or  fibrous 
substance,  or  fluid  contained  in  a  cyst.  These  have  only  cellular 
attachments,  and  are  removed  easily  by  making  an  incision  through 
the  vagina,  and  turning  out  the  tumour,  or  evacuating  its  contents  ;f 
other  tumours  are  cartilaginous,  and  these,  instead  of  being  con- 
nected only  by  cellular  matter,  are  attached  to  the  pelvis  firmly, 
or  grow  from  it.  They  adhere  either  by  a  pedicle,  or  by  an  ex- 
tensive base.  In  the  first  case  the  tumour  is  more  moveable  than 
in  the  second,  where  the  fixture  is  firmer.  These  can  only  be 
extirpated  by  cutting  deeply  into  the  cavity  of  the  pelvis,  and  the 
incision  requires  to  be  made  through  the  perineum  and  levator  ani, 

*  In  all  cases  of  moveable  tumours,  as  well  as  in  stone  in  the  bladder,  it  is  evi- 
dent, that  they  ought,  in  the  very  beginning  of  labour,  to  be  pushed  above  the 
brim,  and  prevented  from  entering  it  before,  or  along  with  the  head. 

■j-  M.  Pelletan  details  several  cases  of  tumours  within  the  pelvis,  some  of  them 
fatty  or  fibrous,  and  easily  turned  out,  merely  by  making  an  incision  .over  them, 
through  the  vagina  ;  one  encysted  containing  puriform  matter  ;  and  one  about 
an  inch  long,  of  a  cartilaginous  nature,  adhering  to  the  descending  branch  of  the 
pubis,  the  vagina  being  divided,  it  was  cut  off  with  scissors.  Clinique  Chirurgi- 
cale,  Tom.  I.  203,  206,  224,  228,  250.  Mr.  Park  likewise  relates  several  cases, 
chiefly  of  tumours  containing  liquid,  or  soft  contents,  and  which  were  pierced 
from  the  vagina  during  labour.    Med.  Chir.  Trans.  II.  293. 


37 

like  the  incision  in  the  operation  of  lithotomy  in  the  male  subject. 
We  are  much  indebted  to  Dr.  Drew  for  the  first  case  of  an  opera- 
tion of  this  kind ;  and  as  the  tumour  adhered  by  a  neck,  it  was 
easily  cut  off,  and  the  success  was  complete.* 

In  a  dreadful  case  which  I  met  with  some  years  ago,  the  attach- 
ments were  extensive,  and  the  tumour  so  large  as  to  fill  the  pelvis, 
and  permit  only  one  finger  to  be  passed  between  it  and  the  right 
side  of  the  basin.  It  adhered  from  the  symphysis  pubis  round  to 
the  sacrum,  being  attached  to  the  urethra,  obturator  muscle,  and 
rectum ;  intimately  adhering  to  the  brim  of  the  pelvis,  and  even 
overlapping  it  a  little  towards  the  left  acetabulum.  It  was  hard, 
somewhat  irregular,  and  scarcely  moveable.  The  patient,  Mrs. 
Broadfoot,  was  in  the  9th  month  of  pregnancy.  There  was  no 
choice,  except  between  the  caesarean  operation,  and  the  extirpa- 
tion of  the  tumour.  The  latter  was  agreed  on  ;  and  with  the  as- 
sistance of  Messrs.  Covvper  and  Russel,  I  performed  it  on  the  16th 
of  March,  a  few  hours  after  slight  labour  pains  had  come  on.  An 
incision  was  made  on  the  left  side  of  the  orifice  of  the  vagina,  peri- 
neum, and  anus,  through  the  skin,  cellular  substance,  and  trans- 
versalis  perinei.  The  levator  ani  being  freely  divided,  the  tumour 
was  then  touched  easily  with  the  finger.  A  catheter  was  intro- 
duced into  the  urethra,  and  the  tumour  separated  from  its  attach- 
ments to  that  part.  It  was  next  separated  from  the  uterus,  vagina, 
and  rectum,  partly  by  the  scalpel,  partly  by  the  finger.  I  could 
then  grasp  it  as  a  child's  head,  but  it  was  quite  fixed  to  the  pelvis. 
An  incision  was  made  into  it  with  the  knife,  as  near  the  pelvis  as 
possible ;  but  from  the  difficulty  of  acting  safely  with  that  instru- 
ment, the  scissors,  guided  with  the  finger,  were  employed  when  I 
came  near  the  back  part;  and  instead  of  going  quite  through,  I 
stopped  when  near  the  posterior  surface,  lest  I  should  wound  the 
rectum,  or  a  large  vessel,  and  completed  the  operation  with  a  spa- 
tula. The  tumour  was  then  removed,  and  its  base  or  attachment 
to  the  bones  dissected  off  as  closely  as  possible.  Little  blood  was 
lost.  The  pains  immediately  became  strong,  and  before  she  was 
laid  down  in  bed  they  were  very  pressing.     In  four  hours  she  was 

*  Vide  Edin.  Med.  &  Surg.  Journal,  vol.  1.  p.  20. 


33 

delivered  oi'  a  still  bom  child,  above  the  average  size.  Peritoneal 
inflammation,  with  considerable  constitutional  irritation,  succeeded; 
but  bv  the  prompt  and  active  use  of  the  lancet  and  purgatives,  the 
danger  was  soon  over,  and  the  recovery  went  on  well.  In  the 
month  of  May  the  wound  was  healed.  On  examining  per  vaginam, 
the  vagina  was  felt  adhering  as  it  ought  to  do,  to  the  pelvis,  rec- 
tum, &tc.  The  side  of  the  pelvis  was  smooth  ;  and  a  person  igno- 
rant of  the  previous  history  of  the  case,  or  who  did  not  see  the  ex- 
ternal cicatrix,  could  not  have  discovered  that  any  operation  had 
been  performed.  After  a  lapse  of  more  than  five  years,  she  still 
continues  well,  but  has  never  been  pregnant. 

The  practical  remarks  which  I  would  offer  on  this  subject,  are, 

1st.  That  whenever  the  tumour  is  moveable,  it  ought  to  be 
pushed  above  the  brim  of  the  pelvis  in  the  commencement  of 
labour,  and  prevented  from  again  descending  before  the  child's 
head. 

2d.  That  on  a  principle  to  be  hereafter  more  fully  inculcated, 
we  ought  never  to  permit  the  labour  to  be  long  protracted,  but 
should  early  resort  to  means  for  relief.  By  a  contrary  conduct  die 
child  indeed  may  be  ultimately  expelled  by  nature,  or  be  brought 
away  by  art,  but  the  mother  is  in  great  danger  of  perishing,  either 
from  subsequent  inflammation  or  exhaustion. 

3d.  As  it  is  impossible  to  decide  with  certainty  on  the  nature  or 
contents  of  many  of  these  tumours,  we  ought,  in  all  cases  where 
we  cannot  push  them  up,  to  try  the  effect  of  puncturing  with  a 
trocar.  If  the  contents  be  fluid,  we  evacuate  them  more  or  less 
completely;  if  solid,  we  find  that  die  canula,  on  being  withdrawn, 
is  empty,  or  filled  with  clotted  blood ;  if  fatty,  or  cheesy,  the  end 
of  the  tube  retains  a  portion ;  and  we  are  thus  informed  of  its 
nature. 

4th.  When  the  size  of  the  tumour  cannot  be  sufficiently,  or  con- 
siderably diminished  by  tapping,  I  am  inclined,  from  the  unfa- 
vourable result  of  cases  where  the  perforator  has  been  used,  and 
from  the  severe  and  long  continued  efforts  which  have  been  re- 
quired  to  accomplish  delivery,  to  recommend  the  extirpation  of 
the  tumour,  rather  than  the  use  of  the  crotchet ;  and  this  may  be 
accomplished  best  and  most  safely  by  the  mode  adopted  in  the 


39 

case  of  Mrs.  Broadfoot.  There  may,  however,  be  situations 
where  this  incision  ought  to  be  made  in  the  vagina;  but  these  are 
rare.  But  extirpation  cannot  in  any  mode  be  proposed,  if  firm 
cohesions  have  been  contracted  between  the  tumour  and  vagina 
or  rectum. 

5th.  If  the  extensive  connections,  extent,  or  nature  of  the  tu- 
mour, or  danger  from  hemorrhage,  prohibit  extirpation,  or  the 
patient  will  not  submit  to  it,  and  if  it  have  been  early  ascertained 
that  tapping  is  ineffectual,  I  deem  it  an  imperative  duty  to  urge  the 
perforation  of  the  head,  or  extraction  of  the  child,  as  soon  as  the 
circumstances  of  the  case  will  permit. 

6th.  Much  and  justly  as  the  caesarean  operation  is  dreaded,  it 
may  with  great  propriety  be  made  a  question,  whether  in  extreme 
cases,  that  would  not  be  less  painful  and  less  hazardous,  to  the 
mother,  than  those  truly  appalling  sufferings  which  are  sometimes 
inflicted  by  the  practitioner  for  a  great  length  of  time,  when  the 
crotchet  is  employed;  whilst  it  would  save  the  child,  if  alive  at  the 
time  of  interference.  I  am  aware  that  it  may  be  objected  to  this 
opinion,  that  in  those  cases,  the  tumour  being  softer  than  bone, 
the  same  injury  will  not  be  sustained  as  if  the  soft  parts  had  been 
pressed  with  equal  force,  and  for  the  same  time,  against  the  bones 
of  a  contracted  pelvis,  and  that  in  point  of  fact,  recovery  has  taken 
place,  although  the  strength  of  two  able  practitioners  was  exerted 
and  exhausted  during  several  hours ;  but  such  an  instance  cannot 
establish  the  general  safety  of  the  practice. 

7th.  It  is  scarcely  necessary  for  me  to  add,  that  there  may  be 
inferior  degrees  of  encroachment,  which  admit  of  the  safe  and  suc- 
cessful application  of  the  forceps  ;  and  of  this  matter  we  judge  by 
the  size  of  the  tumour,  and  capacity  of  the  pelvis.  It  will  hereafter 
be  explained  that  a  very  small  degree  of  obstruction  may  retard 
delivery,  rather  by  influencing  the  action  of  the  uterus,  than  by  the 
mechanical  resistance  opposed. 

§  4.  MEANS  OF  ASCERTAINING  THE  SIZE  OF  THE  HEAD. 

In  order  to  ascertain  the  degree  of  deformity,  and  the  capacity 
of  the  pelvis,  different  instruments  have  been  invented.     Some  of 


40 

these  are  intended  to  be  introduced  within  the  pelvis,  and  others 
to  be  applied  on  the  outside,  deducting  in  the  latter  case,  three 
inches  for  the  thickness  of  the  pubis,  sacrum,  and  soft  parts.  If  the 
finger,  or  any  instrument,  be  carried  from  the  arch  of  the  pubis,  to 
the  top  of  the  sacrum,  about  half  an  inch  is  to  be  deducted  from 
the  measured  distance,  on  account  of  the  obliquity  of  the  line.  But 
these  methods  are  so  very  uncertain,  that  I  do  not  know  any  per- 
son who  makes  use  of  them  in  practice.  The  hand  is  the  best  pel- 
vimeter, and  must  in  all  cases,  where  an  accurate  knowledge  is  ne- 
cessary, be  introduced  within  the  vagina.  By  moving  it  about,  and 
observing  the  number  of  fingers  which  can  be  passed  into  different 
parts  of  the  brim,  or  the  distance  to  which  two  fingers  require  to 
be  separated  in  order  to  touch  the  opposite  points  of  the  brim,  or 
the  space  over  which  one  finger  must  move  in  order  to  pass  from 
one  part  to  another,  we  may  obtain  a  sufficient  knowledge,  not 
only  of  the  shape  of  the  brim,  cavity,  and  outlet  of  the  pelvis,  but 
also  of  the  degree  to  which  the  soft  parts  within  are  swelled,  as 
well  as  of  the  position  and  extent  of  any  tumour  which  may  be 
formed  in  the  pelvis.  We  may  be  further  assisted  by  observing, 
that  in  great  degrees  of  deformity  or  contraction,  the  head  does  not 
enter  the  brim  at  all;  in  smaller  degrees  it  engages  slowly,  and  the 
bones  of  the  cranium  form  an  angle  more  or  less  acute,  according 
to  the  dimensions  of  the  brim  into  which  it  is  squeezed. 

As  in  many  cases  of  deformed  and  contracted  pelvis,  it  is  neces- 
sary to  break  down  the  head  in  order  to  get  it  through  the  cavity, 
it  will  be  proper  to  subjoin  the  dimensions  of  the  foetal  head  when 
it  is  reduced  to  its  smallest  size.  When  the  frontal,  parietal,  and 
squamous  bones  are  removed,  which  is  all  that  we  can  expect  to 
be  done  in  a  case  requiring  the  crotchet,  we  find  that  the  width  of 
the  base  of  the  cranium,  over  the  sphenoid  bone,  is  two  inches  and 
a  half.  The  distance  from  cheek  to  cheek  is  three  inches.  From 
the  chin  to  the  root  of  the  nose  is  an  inch  and  a  half;  and  by  sepa- 
rating the  symphysis  of  the  jaw,  the  two  sides  of  the  maxilla  may 
recede,  so  as  to  make  this  distance  even  less.  From  the  chin  to 
the  nape  of  the  neck,  when  the  chin  is  placed  on  the  breast,  is  two 
inches  and  three  quarters.  When,  on  the  contrary,  the  chin  is 
raised  up,  and  the  triangular  part  of  the  occiput  laid  back  on  the 


41 


neck,  the  distance  from  the  throat  to  the  occiput  is  two  inches. 
The  smallest  part  of  the  head,  then,  which  can  be  made  to  present, 
is  the  face ;  and  when  this  is  brought  through  the  brim,  the  back 
part  of  the  head  and  neck  may,  although  they  measure  two  inches, 
be  reduced  by  pressure  so  as  to  follow  the  face.  The  short  dia- 
meter of  the  chest  when  pressed  is  an  inch  and  a  half;  that  of  the 
pelvis  is  the  same.     The  diameter  of  the  shoulder  is  one  inch. 


CHAP.  VII. 

Of  Augmented  Capacity  of  the  Pelvis. 

A  very  large  pelvis,*  so  far  from  being  an  advantage,  is  at- 
tended with  many  inconveniences,  both  during  gestation  and  par- 
turition. The  uterus,  in  pregnancy,  does  not  ascend  at  the  usual 
time  out  of  the  pelvis,  which  produces  several  uneasy  sensations;  it 
is  even  apt,  owing  to  its  increased  weight,  to  be  prolapsed :  or,  if 
the  bladder  be  distended,  it  may  readily  be  retroverted.  At  the 
very  end  of  gestation,  the  uterus  may  descend  to  the  orifice  of  the 
vagina;  and,  during  labour,  forcing  pains  are  apt  to  come  on  be- 
fore the  os  uteri  be  properly  dilated,  by  which  both  the  child  and 
the  uterus  maybe  propelled,  even  out  of  the  vagina;  and,  in  many 
instances,  although  this  should  not  happen,  yet  the  pains  are  se- 
vere and  tedious,  especially  if  the  practitioner  be  not  aware  of  the 
nature  of  the  case. 

*  The  following  are  the  dimensions  of  a  very  large  pelvis  which  I  possess. 
The  conjugate  diameter  is  four  inches  and  three  fourths  ;  the  lateral,  five  inches 
and  five  eighths ;  the  diagonal,  five  inches  and  a  half.  From  the  symphysis 
pubis  to  the  sacro-iliac  junction,  five  inches.  From  the  top  of  the  arch  of  the 
pubis  to  the  sacrum,  is  five  inches  and  three  eighths.  From  one  tuberosity  of 
the  ischium  to  the  other,  is  five  inches  and  a  half;  and  the  arch  is  very  wide. 
Depth  of  the  pelvis  at  the  sacrum  without  the  coccyx,  five  inches  Breadth  of 
the  sacrum  at  the  top,  four  inches  and  seven  eighths.  Depth  of  the  pelvis  at  th<* 
sides,  four  inches. 


42 


CHAP.  VIII. 

Of  the  External  Organs  of  Generation. 

§    1.  GENERAL  VIEW. 

The  symphysis  of  the  pubis,  and  insertion  of  the  recti-muscles, 
are  covered  with  a  very  considerable  quantity  of  cellular  sub- 
stance, which  is  called  the  mons  veneris.  From  this  the  two  ex- 
ternal labia  pudendi  descend,  and  meet  together  about  an  inch  be- 
fore the  anus;  the  intervening  space  receiving  the  name  of  peri- 
naeum.  On  separating  the  great  labia,  we  observe  a  small  project- 
ing body  placed  exactly  on  the  lower  part  of  the  symphysis.  This 
is  the  clitoris,  and  it  is  surrounded  by  a  duplicature  of  skin  called 
its  prepuce.  From  this  duplicature,  or  rather  from  the  point  of  the 
clitoris,  we  find  arising  on  each  side,  a  small  flap,  which  is  conti- 
nued down  on  the  inside  of  the  labia,  to  the  orifice  of  the  vagina. 
These  receive  the  name  of  nymphas,  or  labia?  minores  or  interiores. 
On  separating  them,  we  observe,  about  nearly  an  inch  below  the 
clitoris,  the  extremity  of  the  urethra;  and,  just  under  it,  the  orifice 
of  the  vagina,  which  is  partly  closed  up,  in  the  infant  state,  by  a 
semilunar  membrane,  called  the  hymen.  These  parts  are  all  com- 
prehended under  the  general  name  of  vulva,  or  external  organs  of 
generation. 

§  2.  LABIA  AND  NYMPHJE. 

The  labia  have  nothing  peculiar  in  their  structure,  for  they  are 
merely  duplicatures  of  the  skin,  rendered  prominent  by  a  deposi- 
tion of  fatty  matter.  Externally  they  have  just  the  appearance 
of  the  common  integuments;  and  at  the  age  of  puberty,  are,  to- 
gether with  the  mons  veneris,  generally  covered  with  hairs.  Inter- 
nally they  resemble  the  inside  of  the  lips  or  eye-lids,  and  are  fur- 
nished with  numerous  sebaceous  glands.    They  are  placed  closer 


43 

together  below  than  above ;  and  at  their  junction  behind,  a  small 
bridle  called  the  fourchette,  extends  across,  which  is  generally  torn 
whenever  a  child  is  born. 

The  nymphae  at  first  appear  to  be  merely  duplicatures  of  the 
inner  surface  of  the  labia,  but  they  are,  in  fact,  very  different  in 
their  structure.  They  are  distinct  vascular  substances  inclosed  in 
a  duplicature  of  the  skin.  When  injected  by  filling  the  pudic  ar- 
tery, each  nympha  is  found  to  be  made  up  of  innumerable  ser- 
pentine vessels,  forming  an  oblong  mass.  This  at  the  upper  part 
joins  the  clitoris,  to  which,  perhaps,  it  serves  as  an  appendage ; 
whilst  the  loose  duplicature  of  skin  in  which  it  is  lodged,  by  being 
unfolded,  permits  the  labia  to  be  more  safely  and  easily  distended, 
during  the  passage  of  the  child. 

§  3.  CLITORIS. 

The  clitoris  is  a  small  body,  resembling  the  male  penis,  but  has 
no  urethra.  It  consists  of  two  corpora  cavernosa,  which  arise  from 
the  rami  of  the  ischia  and  pubis,  and  unite  at  the  symphysis  of  the 
pubis.  These  are  furnished  with  two  muscles  analogous  to  the 
erectores  penis  of  the  male.  When  the  crura  and  nymphae  are 
filled  with  wax,  we  find  on  each  side,  two  vascular  injected 
bodies,  one  of  them  in  close  contact  with  the  bones,  the  other 
more  internal  with  regard  to  the  symphysis  of  the  pubis.  When 
the  one  is  injected,  the  other  is  injected  also,  and  both  are  con- 
nected together  at  the  upper  part.  The  clitoris,  formed  by  the 
junction  of  its  crura,  is  apparently  about  the  eighth  part  of  an  inch 
long,  a  part  of  it  not  being  seen,  and  it  is  supported  by  a  pretty 
strong  suspensory  ligament  which  descends  from  the  symphysis. 
When  distended  with  blood,  it  becomes  erected  and  considerably 
longer,  and  is  endowed  with  great  sensibility. 

§  4.  URETHRA. 

On  separating  the  nymphae,  we  find  a  smooth  hollow  or  channel, 
extending  down  from  the  clitoris  for  nearly  an  inch ;  and  at  the 
termination  of  this,  and  just  above  the  vagina,  is  the  orifice  of  the 


44 

urethra,  which  although  not  one  of  the  organs  of  generation,  de- 
serves particular  attention.  The  bladder  is  lodged  in  the  fore  part 
of  the  pelvis,  immediately  behind  the  symphysis  pubis;  but  when 
distended,  it  rises  up,  and  its  fundus  has  been  known  to  extend 
even  to  the  umbilicus.  The  urethra  is  the  excretory  duct  of  the 
bladder ;  it  is  about  an  inch  and  a  half  long,  and  passes  along  the 
upper  part  of  the  vagina,  through  which  it  may  be  felt  like  a  thick 
fleshy  cord.  The  structure  of  the  urethra  is  extremely  simple,  for 
little  can  be  discovered  except  a  continuation  of  the  internal  coat 
of  the  bladder,  covered  with  condensed  cellular  substance.  On 
slitting  up  the  canal,  numerous  mucous  lacunae  may  be  discovered 
in  its  course,  and  two  of  these  at  the  orifice  are  peculiarly  large. 
The  urethra  is  very  vascular,  and,  when  injected  and  dried,  its  ori- 
fice is  perfectly  red.  In  the  unimpregnated  state,  it  runs  very 
much  in  the  direction  of  the  outlet  of  the  pelvis ;  so  that  a  probe, 
introduced  into  the  bladder,  and  pushed  on  in  the  course  of  the 
urethra,  would,  after  passing  for  about  three  inches  and  a  half, 
strike  upon  the  fundus  uteri,  and,  if  carried  on  for  an  inch  and  a 
half  farther,  would  touch  the  second  bone  of  the  sacrum.  The 
uterus  being  much  connected  with  the  bladder  at  its  lower  part, 
it  follows,  that  when  it  rises  up  in  pregnancy,  the  bladder  will  also 
be  somewhat  raised,  and  pressed  rather  more  forwards,  and  the  va- 
gina being  elongated,  the  urethra,  which  is  attached  to  it,  is  also 
Carried  a  little  higher,  and,  in  its  course,  is  brought  nearer  the  in- 
side of  the  symphysis  pubis.  In  those  women  who,  from  defor- 
mity of  the  pelvis,  or  other  causes,  have  a  very  pendulous  belly, 
the  bladder,  during  pregnancy,  is  sometimes  turned  over  the  pubis, 
the  urethra  curved  a  little,  and  its  opening  somewhat  retracted 
within  the  orifice  of  the  vagina.  When  it  is  necessary  to  pass  the 
catheter,  it  is  of  great  consequence  to  be  able  to  do  it  readily,  and 
this  is  by  no  means  difficult  to  do.  The  woman  ought  to  be  placed 
on  her  back,  with  her  thighs  separated,  and  the  knees  drawn  a  little 
up  :  a  basin  is  then  to  be  placed  betwixt  the  thighs,  or  a  bladder 
may  be  tied  firmly  to  the  extremity  of  the  catheter  to  receive  the 
urine.  The  instrument  is  then  to  be  conveyed  under  the  thigh,  and 
the  labia  separated  with  the  finger.  The  clitoris  is  next  to  be 
touched,  and  the  finger  run  gently  down  the  fossa  that  leads  to  the 


46 

orifice  of  the  urethra,  which  is  easily  distinguished  by  its  resen> 
blance  to  an  irregular  dimple,  situated  just  above  the  entrance  to 
the  vagina.  The  point  of  the  instrument  is  to  be  moved  lightly 
down  the  fossa  alter  the  finger,  and  it  will  readily  slip  into  the 
urethra.  It  is  then  to  be  carried  on  in  the  direction  of  the  axis  of 
the  outlet  of  the  pelvis,  and  the  urine  drawn  off.  This  operation 
ought  always  to  be  performed  in  bed,  and  the  patient  is  never  to 
be  exposed.  In  cases  of  fractures,  bruises,  Sec.  where  the  woman 
cannot  turn  from  her  side  to  her  back,  the  catheter  may  be  intro- 
duced from  behind  without  moving  her.  When  the  bladder  is 
turned  over  the  pubis,  as  happens  in  cases  of  great  deformity  of  the 
pelvis,  it  is  sometimes  requisite  to  use  either  a  flexible  catheter, 
or  a  male  catheter,  with  its  concavity  directed  forward.  When  the 
uterus  is  retroverted,  if  we  cannot  use  a  female  catheter,  Ave  may 
employ  a  gum  catheter.  When  the  head  of  the  child  in  labour  has 
entered  the  pelvis,  the  urethra  is  pushed  close  to  the  symphysis  of 
the  pubis;  then  the  flexible  or  fiatTStheter  must  be  introduced  pa- 
rallel to  the  symphysis,  and  the  head  of  the  child  may  be  raised 
up  a  little  with  the  finger.  This,  indeed,  of  itself,  frequently  per- 
mits the  urine  to  flow ;  and  when  the  urine  is  retained  after  de- 
livery, it  is  often  sufficient  to  raise  up  the  uterus  a  little  with  the 
finger. 

§  5.  ORIFICE  OF  VAGINA  AND  HYMEN. 

The  orifice  of  the  vagina  is  situated  nearly  opposite  to  the  ante- 
rior part  of  the  tuberosity  of  the  ischium,  about  an  inch  and  a  half 
below  the  symphysis  of  the  pubis,  and  in  ihe  direction  of  the  axis 
of  the  outlet  of  the  pelvis.  It  is,  in  all  ages,  but  more  especially  in. 
infancy,  considerably  narrower  than  the  canal  itself,  and  is  sur- 
rounded by  a  sphincter  muscle,  which  arises  from  the  sphincter 
ani,  and  is  accompanied  with  a  vascular  plexus,  called  plexus  reti- 
ibrmis.  In  children,  it  is  always  shut  up  by  a  membrane  called 
the  hymen,  which  consists  of  four  angular  duplicatures  of  the  mem- 
brane of  the  vagina ;  the  union  of  which  may  be  discovered  by 
corresponding  lines  on  the  hymen.  At  the  upper  part  there  is  a 
semilunar  vacancy,  intended  for  the  transmission  of  the  menses. 


46 

Sometimes  it  is  imperforated,  or  partially  or  totally  absorbed. 
When  the  hymen  is  ruptured,  it  is  supposed  to  shrivel  into  three 
or  four  small  excrescences  at  the  orifice  of  the  urethra,  called  the 
carunculse  myrtiformes.(Z) 

Immediately  below  the  orifice  of  the  vagina,  there  is  a  short  sinus 
within  the  labia,  which  extends  farther  back  than  the  vagina.  This 
has  been  called  the  fossa  naviculars,  and  reaches  to  the  fourchette. 


CHAP.  IX. 

Of  the  Internal  Organs  of  Generation. 

* 

ThiI,  internal  organs  of  generation  consist  of  the  vagina,  with  the 
uterus*and,4ts  appendages. 

Tha vagina  is  a  canal  which  extends  from  the  vulva  to  the  womb. 
It  consists  principally  of  a  spongy  cellular  substance,  endowed  with 
some  elasticity,  and  having  an  admixture  of  indistinct  muscular 
fibres.  It  is  lined  by  a  continuation  of  the  cutis  from  the  inner 
surface  of  the  labia ;  and  this  lining,  or  internal  coat,  forms  nume- 
rous wrinkles,  or  transverse  rugae,  on  the  anterior  and  posterior 
sides  of  the  vagina.  They  are  peculiar  to  the  human  female,  and 
are  most  distinctly  seen  in  the  virgin  state;  but  after  the  vagina  has 
been  distended,  they  are  more  unfolded,  and  sometimes  the  surface 
is  almost  smooth.  In  the  whole  course  of  this  coat,  may  be  ob- 
served the  openings  of  numerous  glandular  follicles,  which  secrete 
a  mucous  fluid.  In  the  foetus  this  is  white  and  milky;  in  the  adult 
it  is  nearly  colourless.   The  vagina  is  very  vascular;  and  when  the 

(/)  Haller,  in  his  Elementa  Physiologic,  asserts  that  the  hymen  is  peculiar  to 
the  female  of  the  human  species ;  but  Duverney,  in  a  Memoir  read  before  the  In- 
stitute and  the  School  of  Medicine,  at  Paris,  asserts,  that  it  is  common  to  others  of 
the  mammalia. 


47 

parts  are  well  injected,  dried,  and  put  in  oil  of  turpentine,  the  ves- 
sels are  seen  to  be  both  large  and  numerous.  Just  below  the  sym- 
physis pubis,  we  observe  a  great  congeries  of  vessels  surrounding 
the  urethra  and  upper  part  of  the  vagina. 

The  vagina  forms  a  curved  canal,  which  runs  very  much  in  the 
course  of  the  axis  of  the  outlet  and  cavity  of  the  pelvis.  It  is  not 
round,  but  considerably  flattened ;  it  is  wider  above  than  below, 
being  in  young  subjects  much  contracted  about  the  orifice.  At 
its  upper  part,  it  does  not  join  the  lips  of  the  os  uteri  directly,  but 
is  attached  a  little  above  them,  higher  up  behind  than  before,  so 
that  the  posterior  lip  of  the  uterus  is  better  felt  than  the  anterior. 
In  the  infant,  the  vagina  is  attached  still  higher  up,  so  that  the  lips" 
of  the  uterus  project  in  it  something  like  a  penis. 

The  inner  coat  of  the  vagina  is  reflected  over  the  lips  of  the 
uterus,  and  passes  into  its  cavity,  forming  the  lining  of  the  uterus'. 
The  junction  of  the  uterus  and  vagina  is  so  intimate,  that  we  can- 
not make  an  accurate  distinction  betwixt  them  ;  but  may  say,  that 
the  one  is  a  continuation  of  the  other.  The  vagina  adheres  be- 
fore very  intimately  to  the  urethra,  behind,  it  comes  gradually  to 
approach  to  the  rectum,  and  at  its  upper  part  it  is  pretty  firmly 
connected  to  it.  This  union  forms  the  recto-vaginal  septum* 
These  connections  of  the  vagina  are  formed  by  cellular  substance, 
there  being  only  a  very  small  part  of  its  upper  extremity  covered, 
with  peritoneum. 

When  the  finger  is  introduced  into  the  vagina  in  situ,  the  urethra 
is  felt  on  its  fore  part,  resembling  a  firm  fleshy  cylinder.  Behind, 
the  rectum  can  be  traced  down  to  the  point  of  the  coccyx.  'At 
the  side,  the  ramus  of  the  ischium  and  of  the  pubis,  together  with 
the  obturator  internus  muscle  are  to  be  distinguished.  In  a  well- 
formed  pelvis,  the  finger  cannot  easily  reach  beyond  the  lower 
part  of  the  sacrum  ;  during  labour,  however,  the  parts  being  more 
relaxed,  the  bone  may  be  felt  more  easily,  but  its  promontory  can- 
not be  touched  with  the  finger. 


48 

§  2.  UTERUS  AND  ITS  APPENDAGES. 

The  uterus  is  a  flat  body  somewhat  triangular  in  its  shape,  being 
considerably  broader  at  its  upper  than  at  its  under  part.  It  Ls 
scarcely  three  inches  in  length,  about  two  inches  broad  above,  and 
one  below.  It  is  divided  by  anatomists  into  the  fundus  or  upper 
part,  which  is  slightly  convex,  and  lies  above  the  insertion  of  the 
fallopian  tubes ;  the  cervix  or  narrow  part  below ;  the  body,  which 
comprehends  all  the  space  betwixt  the  fundus  and  cervix ;  and 
last  of  all,  the  os  uteri,  which  is  the  termination  of  the  cervix,  and 
consists  of  a  small  transverse  chink,  the  two  sides  of  which  have 
been  called  the  lips  of  the  uterus.  The  uterus  contains  a  small 
cavity  of  a  triangular  shape,  which  opens  into  a  narrow  channel 
formed  in  the  cervix,  and  is  continued  down  to  the  os  uteri.  At 
the  upper  angles  may  be  perceived  the  openings  of  the  fallopian 
tubes.  Both  the  cavity  and  the  channel  are  lined  with  a  continua- 
tion of  the  inner  coat  of  the  vagina,  but  it  has  a  very  different  ap- 
pearance from  that  which  it  exhibits  in  the  vagina.  The  surface  of 
the  triangular  cavity  is  smooth,  and  the  skin  which  covers  it  is 
very  soft  and  vascular.  The  surface  of  the  cervical  channel  again 
is  rugous,  and  the  rugae  are  disposed  in  a  beautiful  manner,  so  as 
to  have  some  resemblance  to  a  palm  tree.  This  part  is  by  no 
means  so  vascular  as  the  cavity  above  j  but  it  contains  betwixt  the 
rugae  several  lacunae,  which  secrete  a  mucous  fluid.  Where  the 
cavity  of  the  uterus  terminates  in  the  channel  of  the  cervix,  there 
is  sometimes  a  slight  contraction  of  the  passage. 

The  substance  of  the  uterus  is  made  up  of  numerous  ftbres,(m) 
disposed  very  irregularly,  and  having  a  considerable  quantity  of 
interstitial  fluid  interposed,  with  many  vessels  ramifying  amongst 
them.  A  dense  succulent  texture  is  thus  formed,  which  consti- 
tutes the  substance  of  the  uterus.  On  cutting  open  the  womb,  we 
observe  that  its  sides  are  about  a  quarter  of  an  inch  thick,  but  are 
rather  thinner  at  the  fundus,  than  elsewhere,  though  the  difference 
is  very  trifling.     Several  irregular  apertures  may  be  perceived  on 

CmJ  The  reader  is  referred  to  a  very  interesting  paper  "  on  the  muscularity 
of  the  uterus,  by  Charles  Bell,  Esq.  F.  R.  S.  Ed.  &c."  published  in  the  5th  vol, 
of  the  Eclectic  Repertory,  p.  27,  and  §  9. 


49 

the  cut  surface  :  these  are  the  veinous  sinuses.  The  fibres  which 
we  discover  are  muscular;  but  we  cannot,  in  the  unimpregnated 
state,  observe  them  to  follow  any  regular  course. 

The  arteries  of  the  uterus  are  four  in  number,  with  correspond- 
ing veins.  The  two  uppermost  arteries  arise  either  high  up  from 
the  aorta,  or  from  the  emulgent  arteries.  They  descend,  one  on 
each  side,  in  a  serpentine  direction  behind  the  peritoneum,  and 
arc  distributed  on  the  ovaria,  tubes,  and  upper  part  of  the  uterus. 
These  are  called  spermatic  arteries.  The  two  lowermost,  which 
are  called  uterine,  arise  from  the  hypogastric  arteries.  They  run, 
one  on  each  side,  toward  the  cervix  uteri,  and  supply  it  and  the 
upper  part  of  the  vagina.  Thus  the  fundus  uteri  is  supplied  by 
the  spermatic  arteries,  and  the  cervix,  by  the  uterine  arteries; 
and  these,  from  opposite  sides,  send  across  branches  which  com- 
municate one  with  the  other.  But  besides  this  distribution,  the 
uterine  artery  is  continued  up  the  side  of  the  uterus,  and  meets 
with  the  spermatic,  so  that,  at  the  two  sides,  we  have  arterial 
trunks,  from  which  the  body  of  the  uterus  is  liberally  supplied  with 
blood.  The  veins  correspond  to  the  arteries.  The  nerves  of  the 
uterus,  like  the  blood-vessels,  have  also  a  double  origin,  and  follow 
nearly  the  same  course.  Those  which  come  from  below  are  de- 
rived from  the  sacral  nerves,  especially  from  the  fourth  pair.  Those 
from  above  come  chiefly  from  the  mesocolic  plexus,  and  trunk  of 
the  intercostal.  The  renal  plexus  furnishes  nerves  to  the  ovarium, 

The  lymphatics,  in  the  unimpregnated  state  of  the  uterus,  are 
small,  and  not  easily  discovered.  Those  from  the  upper  part  of 
the  womb,  and  from  the  ovaria,  run  along  with  the  spermatic  ves- 
sels, terminating  in  glands  placed  by  the  side  of  the  lumbar  verte- 
brae. Hence,  in  diseases  of  the  ovaria,  there  may  be  both  pain 
and  swelling  of  the  glands.  But  the  greatest  number  of  lymphatics 
run  along  with  the  uterine  artery,  several  of  them  passing  to  the 
iliac  and  sacral  glands,  and  some  accompanying  the  round  liga- 
ment. This  may  explain  why,  in  certain  conditions  of  the  uterus, 
the  inguinal  glands  swell.  Others  run  down  through  the  glands  of 
the  vagina ;  and  hence,  in  cancer  of  the  womb,  we  often  feel  those 
glands  hard  and  swelled,  sometimes  to  such  a  degree,  as  almost 
to  close  up  the  vagina-. 

8 


50 

Tire  uterus  is  covered  with  the  peritoneum,  which  passes  off 
from  its  sides,  to  reach  the  lateral  part  of  the  pelvis,  a  little  before 
the  sacro-iliac  symphysis ;  and  those  duplicatures,  which,  when 
the  uterus  is  pulled  up,  seem  to  divide  the  cavity  of  the  pelvis  into 
two  chambers,  are  called  very  improperly  the  broad  ligaments  of 
the  uterus. 

When  the  uterus  is  raised,  and  those  lateral  duplicatures  of  the 
peritoneum  are  stretched  out,  we  observe,  that  at  the  upper  part 
they  form  two  transverse  folds  or  pinions,  one  before  and  the  othex' 
behind.  In  the  first  of  these,  the  fallopian  tubes  are  placed :  in 
the  second,  the  ovaria. 

Besides  these  duplicatures,  we  likewise  remark  other  two  which 
extend  from  the  sides  of  the  fundus  uteri  to  the  linea  iliopectinea 
at  the  side  of  the  pelvis,  and  then  run  on  to  the  groin.  These 
contain,  on  each  side,  a  pretty  thick  cord,  which  arises  from  the 
iundus  uteri,  and  passes  out  at  the  inguinal  canal,  being  then  lost 
in  the  labia  pudendi.  These  cords,  which  are  called  the  round 
ligaments  of  the  uterus,  consist  of  numerous  blood-vessels,  some 
lymphatics,  small  nerves,  and  fibrous  matter. 

The  fallopian  tubes,  in  quadrupeds,  are  merely  continuations  of 
the  horns  of  the  uterus ;  but  in  the  human  female,  they  are  very 
different  in  their  structure  from  the  womb.  They  appear  to  con- 
sist in  a  great  measure,  of  spongy  fibrous  substance,  which,  as  Hal- 
ler  observes,  may  be  inflated  like  the  clitoris.  They  are  hollow, 
forming  a  canal  of  about  three  inches  long,  lined  with  a  continua- 
tion of  the  internal  coat  of  the  uterus ;  and  as  they  lie  in  the  ante- 
rior pinion  of  the  broad  ligaments  of  the  uterus,  they  are  covered 
ol  necessity  with  a  peritoneal  coat.  They  originate  from  the  up- 
per corners  of  the  uterine  cavity  by  very  small  orifices,  but  termi- 
nate at  the  other  extremity  in  an  expanded  opening  with  ragged 
margins,  which  are  called  the  fimbriae  of  the  tube.  The  internal 
surface  of  the  canal  is  plaited,  the  plicae  running  longitudinally. 

The  ovaria*  lie  in  the  posterior  pinion  of  the  broad  ligament. 
They  are  two  oval  flattened  bodies,  of  a  whitish  colour,  and  glan- 

*  In  birds,  we  find  that  the  ovaria  contain  a  great  number  of  yolks  of  different 
sizes.    Those  which  are  nearest  the  wide  canal  called  tke  oviduct  which  leads 


51 

Uular  consistence.  They  are  cellular,  but  not  very  vascular,  al- 
though vessels  run  to  their  coat.  After  puberty,  they  contain 
numerous  minute  vesicles,  the  largest  of  which  are  near  the  sur- 
face, and  even  form  slight  projections  from  it.  These  are  the  ova 
of  the  female,  and  are  filled  with  a  coagulable  lymphatic  matter. 
Their  number  is  uncertain,  but  Haller  says  he  never  saw  above 
fifteen  in  one  woman.     In  old  women  they  disappear  or  shrivel. 

The  ovarium  is  covered  with  the  peritoneum ;  but  when  the 
ovum  is  impregnated  and  becomes  prominent,  the  peritoneum 

to  the  cloaca,  are  largest,  whilst  those  remote  from  it  are  very  minute.  The  full 
grown  yolk  is  detached  from  the  ovarium,  and  in  its  passage  down  is  furnished 
both  with  the  albumen  and  the  necessary  membranes  and  shell.  In  viviparous 
fishes,  as  the  skate,  ray,  &c.  the  same  structure  obtains.  These  animals  have 
two  ovaria,  containing  eggs  of  different  sizes ;  the  smaller  are  white,  the  larger 
yellowish,  and  they  pass  down  to  an  oviduct,  which  contains  a  glandular 
body  that  furnishes  the  covering  of  the  egg.  Each  ovary  has  a  separate  ovi- 
duct, which  forms  a  vast  sac,  that  terminates  in  the  sides  of  the  cloaca, 
by  orifices  that  have  a  duplicature  like  a  valve.  The  cloaca  itself  forms  an 
ample  reservoir,  that  seems  more  like  a  continuation  of  the  oviduct  than  the 
termination  of  the  rectum.  In  oviparous  fishes,  the  ovaria  are  known  under  the 
name  of  roes,  and  all  the  visible  eggs  are  of  the  same  size,  and  so  numerous, 
that  some  contain  above  200,000.  They  are  enveloped  in  a  fine  transparent 
membrane  ;  and  septa  from  this  envelope,  divide  the  internal  parts,  and  furnish 
points  of  attachment  to  the  ova,  which  are  expelled  previous  to  fecundation. 
These  are  called  oviparous  fishes,  and  have,  properly  speaking,  no  oviduct.  The 
ovaria  of  frogs  resemble  those  of  fishes,  and  the  ova  are,  previous  to  expulsion, 
enveloped  in  a  glary  fluid.  In  the  slug  we  find  both  testicles  and  ovaria.  The 
ovarium  is  a  grape-like  tissue,  containing  numerous  small  grains,  or  ova,  attached 
by  pedicles,  which  are  canals  that  lead  into  the  oviduct.  This  is  a  serpentine 
canal,  that  after  having  adhered  to  the  testicle,  opens  in  the  common  cavity  of 
generation,  in  which  also  the  penis  or  duct  from  the  testicle  opens,  and  during 
copulation,  the  two  individuals  mutually  impregnate  each  other.  The  ovaria  of 
the  adder  are  like  strings  of  beads. 

In  many  quadrupeds,  the  ovaria  contain  ova  almost  as  distinct  as  some  of  those 
animals  I  have  just  noticed.  The  hedgehog  has  an  ovarium  like  a  bunch  of 
grapes;  and  the  ovarium  of  the  civet  has  a  knotted  surface,  and  resembles  a 
packet  of  little  spheres :  the  ovarium  of  the  didelphis  is  also  vesicular.  The 
common  sow  has  also  an  ovarium  somewhat  resembling,  externally,  that  of  ovi- 
parous animals.  Most  other  quadrupeds  have  an  ovarium  more  smootli  and 
somewhat  oblong  in  shape,  and  in  general  the  tube  and  ovarium  are  unconnected, 
as  in  the  human  female  ;  but  in  the  otter,  my  brother  observed,  that  both  were 
contained  in  a  kind  of  capsule  formed  by  the  peritoneum,  so  that  ventral  extra 
uterine  pregnancy  cannot  take  place  in  this  animal. 


52 

which  covers  it  is  absorbed,  the  ovum  passes  into  the  fallopian 
tube,  and  the  little  scar  which  remains  on  the  surface  of  the  ova- 
rium, is  called  corpus  luteum.* 

In  the  foetus,  the  ovaria  and  tubes  are  placed  on  the  psoce  mus- 
cles; but  in  the  adult,  they  lie  loosely  in  the  pelvis,  and  the  uterus 
sinks  within  the  cavity.  The  os  uteri  is  directed  forward,  and  the 
fundus  backward,  being  in  general  found  opposite  to,  or  resting  onf 
the  second  bone  of  the  sacrum. 


CHAP.  X. 

Of  the  Diseases  of  the  Organs  of  Generation. 
§  1.  ABSCESS  IN  THE  LABIUM. 

The  labia  are  subject  to  several  diseases :  of  these,  the  first 
which  I  shall  mention,  is  phlegmonoid  inflammation.  This  may 
occur  at  any  period  of  life,  and  under  various  circumstances ;  but 
frequently  it  takes  place  in  the  pregnant  state,  especially  about  the 
sixth  and  seventh  month  of  gestation.  Sometimes  it  appears  sud- 
denly, and  oftener  than  once  in  the  same  pregnancy.  Occasionally 
it  makes  its  attack  in  childbed  in  consequence  of  the  violence 
which  the  parts  may  have  sustained  in  labour.  It  is  marked  by 
the  usual  symptoms  of  inflammation,  namely,  heat,  pain,  throbbing, 
and  more  or  less  swelling,  not  unfrequently  attended  with  fever. 
The  swelling  is  sometimes  hard  and  moveable,  like  a  gland,  espe- 
cially when  the  progress  is  slower  than  usual.  In  general,  the 
course  of  the  disease  is  rapid,  the  pain  and  inflammation  are  at 
first  very  acute,  and  the  part  swells  speedily.  In  a  few  hours,  es- 
pecially if  a  poultice  have  been  applied,  the  abscess  begins  to  point 

*  Sir  E.  Home  asserts,  that  the  Corpora  lutea  exists  previously  to  impregna- 
tion ;  and,  in  the  virgin  state,  that  they  are  solid,  compact,  glandular  substances, 
in  which  the  ovum  is  formed ;  and  after  the  ovum  is  expelled,  the  blood  which 
fills  up  the  cavity  is  gradually  absorbed,  leaving  a  small  cavity,  which  marks  the 
place  where  the  ovum  had  been.    Vide  Philos.  Transact,  years  1817  &  1819. 


53 

at  the  inside  of  the  labium,  and  the  nympha  either  disappears,  or  if 
it  remain,  it  is  pushed  out  of  its  place.  Sometimes  it  bursts  within 
thirty-six  hours  from  its  appearance.  By  means  of  cold  saturnine 
applications,  and  gentle  laxatives,  the  inflammation  may  perhaps  be 
resolved  but  most  frequently  it  ends  in  suppuration,  which  is  to  be 
promoted  by  fomentations  and  warm  cataplasms.  If  necessary,  an 
opiate  may  be  given  to  abate  the  pain,  and  a  pillow  must  be  placed 
between  the  knees,  to  keep  the  part  from  pressure.  If  possible, 
abscess  ought  not  to  be  punctured  ;  but,  if  the  pain  and  tension  be 
unbearable,  we  must  indulge  the  patient  by  making  a  small  open- 
ing ;  a  good  deal  of  blood  will  in  this  case  come  with  the  matter. 
After  the  abscess  bursts,  the  parts  may  be  dressed  with  any  mild 
ointment.  Should  the  opening  of  the  abscess  be  higher  than  ils 
bottom,  it  will  be  necessary,  if  the  discharge  continue,*  to  lay  it 
open,  after  which  it  will  speedily  heal. 


6  2.  ULCERATION  OF  THE  LABIA. 

The  internal  surface  of  the  labia  is  often  the  seat  of  ulceration 
and  excoriation,  which  may  generally  be  avoided  by  the  daily  use 
of  the  bidet.  The  general  form  under  which  excoriation  appears, 
is  that  of  a  raw  surface,  as  if  the  cuticle  had  been  peeled  from  a 
blistered  part.  Most  frequently  these  sores  are  the  consequence  of 
acrimony,  produced  by  inattention  to  cleanliness,  especially  in 
children ;  and  in  their  case  the  labia,  if  care  be  not  taken,  may 
cohere.  The  treatment  consists  in  keeping  the  parts  clean,  bathing 
the  sore  with  a  weak  solution  of  the  sulphate  of  zinc,  and  prevent- 
ing cohesion.  Should  the  parts  not  heal  readily,  they  may  be 
washed  with  brandy,  or  a  very  weak  solution  of  nitrate  of  silver,  or 
touched  with  caustic.  When  adhesion  takes  place,  it  may,  if  slight, 
be  destroyed,  by  gently  pulling  the  one  labium  from  the  other ;  if 
firmer,  the  parts  must  be  separated  wTith  a  knife.  In  either  case, 
reunion  must  be  prevented  by  washing  the  surface  frequently  with 
solution  of  alum,  and  applying  a  small  piece  of  lint  spread  with 
simple  ointment.    Simple  itching  of  the  parts  may  be  removed  by 

*  Vide  Mr.  Hey's  Surgical  Observations,  p.  188. 


64 

the  tepid  bath,  a  dose  of  castor  oil,  and  fomenting  the  parts  with 
milk  and  water. 

Sometimes  we  meet  with  deeper  ulcerations,  which  it  is  of  great 
importance  to  the  domestic  happiness  of  individuals  to  distinguish 
from  chancre.  Nothing  seems  easier  in  a  book,  than  to  make 
the  diagnosis,  but  in  practice  it  is  often  very  difficult.  A  well- 
marked  chancre  begins  with  circumscribed  inflammation  of  the 
part;  then  a  small  vesicle  forms,  which  bursts,  or  is  removed  by 
slough,  and  displays  a  hollow  ulcer,  as  if  the  skin  had  been  scooped 
away  or  nibbled  by  a  small  animal;  its  surface  is  not  polished,  but 
rough,  and  covered  with  pus,  which  is  generally  of  a  buff  or  dusky 
hue;  the  margins  are  red,  and  the  general  aspect  of  the  sore  is 
angry.  But  the  most  distinguishing  character  of  the  chancre  is 
considered  to  be  a  thickening  or  hardness  of  the  base  and  edges 
of  the  ulcer.  The  progress  of  the  sore  is  generally  slow  either 
towards  recovery  or  augmentation.  When  remedies  are  used,  the 
first  effect  produced  is  removing  the  thickening  by  degrees,  and 
lessening  the  discharge,  or  changing  its  nature,  so  mat  the  surface 
of  the  sore  can  be  seen;  it  has  then  in  general  a  dark  fiery  look, 
which  continues  until  all  the  diseased  substance  be  removed,  and 
the  action  of  the  part  be  completely  changed.  Now,  from  this 
description,  we  should,  it  may  be  supposed,  be  at  no  loss  in  say- 
ins,  whether  a  sore  were  venereal;  but  in  practice,  we  find  many 
deviations  from  this  description.  The  thickening  may  be  less  in 
one  case  than  another,  and  may  not  be  easily  discovered,  yet  the 
sore  may  be  certainly  venereal.  Peculiarity  of  constitution,  or  of 
the  part  affected,  can  modify  greatly  the  effects  of  the  virus.  There 
may  be  extensive  inflammation,  or  phagedenic  ulceration;  and 
vet  the  action  may  be  venereal.  It  is,  however,  satisfactory  to 
know  in  these  cases,  that  in  a  little  time,  unless  extensive  slough- 
ing-have  taken  place,  the  appearance  of  the  sore  becomes  more 
decided,  the  proper  character  of  chancre  appears,  and  the  usual 
remedy  cures  the  patient. 

Phagedena  is  a  very  troublesome,  and  sometimes  a  formidable 
disease,  especially  to  infants.  I  shall  here  only  notice  that  form 
which  appears  in  adults,  and  which,  as  it  is  infectious,  may  be 
mistaken  for  syphilis.     It  commences  with  a  livid  redness  of  the 


part,  succeeded  speedily  by  vesication  and  ulceration,  which  ex- 
tends laterally,  and  sometimes  penetrates  deep.  The  ulcer  has  an 
eating  appearance,  is  painful,  discharges  a  great  quantity  of  mat- 
ter, and  very  often  is  attended  with  fever.  A  variety  of  this  dis- 
ease is  attended  with  superficial  sloughing,  which  may  be  fre- 
quently repeated,  and  is  generally  preceded  by  a  peculiar  appear- 
ance of  cleanness  in  the  sore.  This  is  not  to  be  confounded  with 
slou»hin°-,  produced  by  simple  inflammation  or  irritation  of  the 
parts,  which  is  similar  in  its  nature  and  treatment  to  common 
gangrene.  We  must  foment  the  sore  with  decoction  of  camomile 
flowers,  mixed  with  a  little  tincture  of  opium,  and  then  apply  mild 
dressings.  Rest  is  essential  to  the  cure:  and  if  a  febrile  state 
exist,  it  is  to  be  obviated  by  laxatives,  acids,  mild  diaphoretics, 
and  decoction  of  bark.  If  there  be  no  fever,  mercury,  or  the 
nitrous  acid,  often  effectually  change  the  action  of  the  parts. 

Sometimes  irritable  sores  appear  on  different  parts  of  the  labia, 
or  orifice  of  the  vagina,  in  succession,  healing  slowly  one  after  ano- 
ther. These  have  an  inflamed  appearance,  the  margins  are  some- 
times tumid,  and  the  surface  is  at  first  irregular  and  depressed,  but 
afterwards  it  forms  luxuriant  granulations.  There  is  another  sore 
met  with  on  the  inside  of  the  labium,  and  which  generally  spreads 
to  the  size  of  a  sixpence.  The  surface  is  quite  flat,  and  sunk  a 
little  below  the  level  of  the  surrounding  parts.  The  margins  are 
thickened,  and  sometimes  callous,  the  discharge  thin,  and  the  ulcer 
not  in  general  painful,  the  surface  soft  and  spongy  without  a  hard 
base.  These  sores  generally  agree  best  with  stimulants,  especially 
caustic  and  escharotics.  When  they  do  not  yield  to  this  treatment, 
it  will  be  proper  to  have  recourse  to  a  cautious  course  of  mercury. 
Some  of  these,  like  the  phagedena,  are  infectious. 

Some  of  these  sores  are  occasionally  productive  of  secondary 
symptoms,  such  as  ulcers  in  the  throat.  When  these  succeed  a 
sore  which  has  run  its  course  differently  from  chancre,  and  been 
healed  without  the  use  of  mercury,  it  is  allowable  to  suppose,  that 
they  also  may  be  cured,  merely  by  attending  to  the  general  health, 
and  perhaps  by  local  applications.  But  if  they  continue  without 
amendment,  or  threaten  danger  to  any  important  part,  we  raual  not 
delay  making  trial  of  mercury. 


56 


§  3.  EXCRESCENCES  ON  THE  LABIA. 

Sometimes  after  a  slight  degree  of  inflammation,  producing: 
heat  and  itching  of  the  parts,  numerous  excrescences  appear  with- 
in the  labia.  These  are  either  soft  and  fungous,  or  hard  and 
warty.  Both  of  these  states  may  be  induced  by  previous  venereal 
inflammation  ;  but  they  may  also  occur  independently  of  that  dis- 
ease. Even  where  there  is  an  offensive  discharge  from  the  fungi 
or  warts,  we  are  not  always  to  conclude  that  they  are  syphilitic, 
but  be  guided  in  our  judgment  by  concomitant  circumstances. 
Warty  excrescences  are  most  readily  removed,  by  the  application 
of  savin  powder  by  itself,  or  mixed  with  red  precipitate;  and  during 
its  operation,  the  parts  may  be  washed  with  lime  water.  The 
powder  must  be  applied  to  the  roots  of  the  warts,  for  their  sub- 
stance is  almost  insensible.  Fungous  excrescences  may  sometimes 
be  removed  by  ligature ;  but  when  the  parts  are  sensible,  they  must 
be  destroyed,  by  applying  a  strong  solution  of  caustic  with  a  pen- 
cil, or  sprinkling  them  with  escharotic  substances.  If  these  cannot 
be  borne,  we  must  first  abate  the  sensibility  by  tepid  fomentations 
with  decoction  of  poppies,  or  water  with  a  little  tincture  of  opium, 
or  decoction  of  cicuta,  or  weak  infusion  of  belladona.  Should 
there  be  ground  for  suspecting  a  syphilitic  action,  mercury  must 
be  given,  at  the  same  time  that  we  make  suitable  local  applica- 
tions; but  in  doubtful  cases,  I  have  seen  this  medicine  given  with- 
out any  benefit.  These  excrescences,  from  their  appearance,  their 
great  pain,  and  foetid  discharge,  may  suggest  an  opinion  of  their 
being  cancerous :  but  they  begin  in  a  different  way,  and  generally 
yield,  though  sometimes  slowly,  to  proper  applications. 

§  4.  SCIRRHOUS  TUMOURS. 

Solid  tumours  may  form  in  the  labia,  and  are  distinguished  by 
their  hardness,  and  by  their  moving  under  the  skin,  until  adhesion 
from  inflammation  takes  place.  These  tumours  are  sometimes 
scrophulous  and  have  little  pain,  even  when  they  have  gone  on  to 
suppuration.  Oftener,  however,  they  are  cancerous;  and  these 
are  distinguished  from  the  former,  by  their  great  hardness  and  ine- 


57 

quality,  and  by  their  shooting  pain.  If  they  are  not  removed,  the 
cancerous  abscess  points  to  the  inner  surface  of  the  labium,  its  top 
becomes  dark  coloured,  sloughs  off,  a  red  fluid  is  discharged,  and 
presently  fungus  appears.  Soon  after  this,  the  glands  at  the  top 
of  the  thigh,  and  sometimes  those  in  the  course  of  the  vagina, 
swell.  If  all  the  diseased  parts  can  be  removed,  an  operation  must 
be  performed.  If  they  cannot,  we  must  palliate  symptoms  by 
proper  dressing  and  opiates.(n) 

• 

§  5.  POLYPOUS  TUMOURS. 

Soft  fleshy  appendicular,  or  firm  polypous  tumours,  sometimes 
spring  from  the  labia.  Both  of  these,  especially  the  latter,  may 
give  trouble  by  their  weight  or  size.  They  may  also,  by  being 
fretted,  come  to  ulcerate,  and  the  ulceration  is  always  of  a  disa- 
greeable kind.  They  ought  to  be  therefore  early  removed  by  the 
knife  or  the  ligature.  If  the  base  be  broad,  the  double  ligature 
must  be  employed :  but  should  there  be  any  hardness  about  the 
part  where  the  ligature  would  be  applied,  it  is  best  to  dissect  the 
whole  growth  out. 

Encysted  tumours  may  form  in  the  labia.  They  are  elastic,  and 

(n)  An  immense  tumour  was  successfully  extirpated  from  the  labia  of  a  negro 
woman  by  Dr.  Hartshorne  at  the  Pennsylvania  Hospital,  in  December,  1815, 
said  to  be  produced  by  the  kick  of  a  horse,  and  of  upwards  of  ten  years  stand- 
ing. 

In  this  case,  the  labia  were  much  enlarged,  and  almost  as  hard  as  cartilage. 
The  hardness  and  enlargement  of  the  integuments  extended  anteriorly  three 
inches  above  the  pubis,  and  posteriorly  to  within  two  inches  of  the  anus.  The 
patient  walked  with  great  difficulty,  as  the  circumference  of  the  middle  of  the 
tumour  was  at  least  twenty  inches,  and  its  lower  part  almost  reached  the  knees. 
The  weight  of  the  tumour  removed,  was  upwards  of  eleven  pounds. 

On  the  evening  of  the  third  day  after  the  operation,  unequivocal  symptoms  of 
Tetanus  appearing,  and  the  violence  of  the  spasms  increasing,  caustic  potash  was 
freely  applied  to  the  neck,  over  the  cervical  vertebra.  The  effect  of  this  appli- 
cation in  lessening  the  convulsive  action  of  the  muscles  was  very  evident. 

The  woman  was  discharged  well,  on  the  6th  of  April,  ensuing. 

In  Larrey's  Memoirs,  vol.  1.  p.  299,  will  be  found  a  description  of  a  similar 
tumour;  and  in  plate  X.  an  engraving. 

0 


58 

contain  a  glairy  fluid.     The  cyst  may  be  laid  open,  or  it  is  to  be 
dissected  out.(o) 

§  6.  (EDEMA. 

(Edematous  tumour  of  the  labium  is  either  a  consequence  of 
pregnancy,  or  a  symptom  of  general  dropsy.  The  tumour  is  va- 
riable in  its  size.  When  it  depends  on  pregnancy,  it  is  seldom 
necessary  to  do  any  thing ;  and  even  in  time  of  labour,  although 
the  tumour  be  great,  we  need  be  under  little  apprehension,  for  it 
will  yield  to  the  pressure  of  the  child's  head.  But  if  at  any  time, 
during  gestation,  the  distention  be  so  great  as  to  give  much  pain, 
then  one  or  two  punctures  may  be  made,  in  order  to  let  out  the 
fluid  5  but  this  is  very  rarely  necessary.  Gentle  laxatives  are 
generally  useful.  Blisters  applied  to  the  vicinity  of  the  part  have 
been  proposed  ;  but  they  are  painful  and  even  dangerous.  When 
the  swelling  depends  on  dropsy,  diuretics  are  to  be  employed  ; 
but  if  the  woman  be  pregnant,  they  must  be  used  cautiously. 

§  7.  HERNIA,  LACERATION,  &c. 

Pudendal  hernia  is  formed  in  the  middle  of  the  labium.  It 
may  be  traced  into  the  cavity  of  the  pelvis,  on  the  inside  of  the 
ramus  of  the  ischium,  and  can  be  felt  as  far  as  the  vagina  extends. 
It  differs  farther  from  inguinal  hernia,  which  also  lodges  in  the  la- 
hium,  in  this,  that  there  is  no  tumour  discoverable  in  the  course  of 
the  round  ligament  from  the  groin.  It  sometimes  goes  up  in  a 
recumbent  posture,  or  it  may  by  pressure  be  returned.  A  pessary 
has  little  effect  in  keeping  it  up,  unless  it  be  made  inconveniently 
large.  It  is  not  easy  to  adapt  a  truss  to  it,  but  some  good  is  done 
with  a  firm  T-bandage,  or  one  similar  to  that  used  for  prolapsus 
ani.  If  it  cannot  be  reduced,  we  must  support  it  by  a  proper 
bandage,  which  is  not  to  be  drawn  tight. 

Sometimes  the  labia  are  naturally  very  small,  at  other  times  un- 
commonly large  ;  one  side  may  be  larger  than  the  other. 


Co)  "Would  it  not  be  more  eligible,  when  practicable,  to  extirpate  the  cyst 
completely  by  the  knife,  to  prevent  the  risk  of' its  sloughing  away  ? 


59 

Laceration  of  the  labia  is  to  be  treated  like  other  wounds. 
When  the  hemorrhage  is  great,  the  vagina  must  be  plugged,  and  a 
firm  compress  applied  externally,  with  a  proper  bandage. 

§  8.  DISEASES  OF  THE  NYMPHS. 

The  most  frequent  disease  to  which  the  nympha  is  subject  is 
elongation.  When  the  part  protrudes  beyond  the  labia,  it  becomes 
covered  with  a  white  and  more  insensible  skin.  But  sometimes  it 
is  fretted,  on  which  account,  or  from  other  causes,  women  submit 
to  have  the  nympha  cut  away.  This  is  done  at  once  by  a  simple 
incision,  but,  as  the  part  is  exceedingly  vascular,  we  must  after- 
wards restrain  the  hemorrhage,  either  with  a  ligature  or  by  pres- 
sure. By  neglect,  the  patient  may  lose  blood,  even  ad  deliquium. 
In  some  countries,  this  elongation  of  the  nympha  is  very  common.* 
In  others,  the  nymphae,  together  with  the  preputium  clitoridis,  are 
removed  in  infancy. f  The  nymphae  are  subject  to  ulceration,  tu- 
mour, and  other  diseases,  in  common  with  the  labia. 

Sometimes  by  falls,  but  oftenerj  in  labour,  the  vascular  struc- 
ture of  the  nympha  is  injured,  and  a  great  quantity  of  blood  is 
poured  out  into  the  cellular  substance  of  the  labium,  producing  a 


*  The  females  amongst  the  Bosjesmans  have  the  nymphae  sometimes  five  inches 
long.  Their  colour  is  a  livid  blue,  like  the  excrescence  of  a  turkey.  Vide  Bar- 
vow's  Travels  in  Africa,  Vol.  1.  p.  279. 

f  On  the  shores  of  the  Persian  gulph,  among  the  Christians  in  Abyssinia,  and  in 
Egypt  among  the  Arabs  and  Copts,  girls  are  circumcised.  Niebuhr  says,  that 
at  Kahira,  the  women  who  perform  this  operation  are  as  well  known  as  midwives  . 
Travels,  Vol.  II.  p.  250. — l)r  Winterbottom,  in  his  account  of  Sierra  Leone,  Vol. 
II.  p.  239,  says  it  is  practised  among  the  Mandingo,  Foola,  and  Soosoo  women. 

i  M.  Causaubon  has  inserted  a  memoir  on  this  subject,  in  the  1st  Vol.  of  I!e- 
cueil  Periodique,  which  contains  several  useful  cases.  In  one  of  these,  the  tu- 
mour was  produced  on  the  seventh  month  by  a  kick,  and  terminated  fatally  by 
hemorrhage.— In  another  given  by  Sedillot,  the  labia  became  prodigiously  dis- 
tended during  labour,  and  the  head  of  the  child  could  not  be  touched.  The 
labia  were  torn  by  the  attendant.  Afterward  the  child  was  delivered  with  the 
lever.— In  cases  related  by  Baudelocque,  Brasdor,  8cc.  the  tumours  were  opened, 
and  the  vagina  plugged,  whilst  the  wound  was  stuffed  with  lint  dipped  in  solution 
of  alum,  to  prevent  hemorrhage. 


60 

black  and  very  painful  tumour.*  This  may  take  place  even  be- 
fore the  child  is  expelled  ;  and,  in  a  case  of  this  kind,  the  midwife, 
mistaking  the  swelling  for  the  protruded  membranes,  actually  per- 
forated the  labium,  and  caused  a  considerable  discharge  of  blood.f 
More  frequently,  however,  the  tumour  appears  immediately  after 
deli  very,  J  and  the  attention  is  directed  to  it  both  by  its  magnitude 
and  its  sensibility,  which  is  sometimes  so  great  as  to  cause  syn- 
cope. It  is  tense,  throbbing,  and  may  also  be  accompanied  by 
severe  pain  in  the  legs,  and  violent  bearing-down  efforts,^  as  if 
another  child  were  to  be  born,  or,  as  if  the  womb  were  inverted. 
It  has,  however,  been  known  to  advance  so  slowly,  as  not  to  at- 
tract attention  for  two  days.  There  are  also  instances  where  the 
inflammation  runs  high,  and  the  recto-vaginal  septum  sloughing, 
faeces  are  discharged  by  the  vagina. || 

In  the  course  of  a  short  time  the  tumour  bursts,  and  clotted  and 
fluid  blood  is  discharged.  This  process  should  be  hastened  by 
fomentations  and  poultices,  and  the  pain  be  abated  by  opiates ; 
but  if  it  be  very  great,  relief  may  be  obtained  by  making  a  small 
puncture  in  the  inside  of  the  labium.1T    Whether  the  tumour  burst, 


*  In  a  case  related  by  Mr.  Reeve,  the  tumour,  which  I  suspect  proceeded  from 
the  rupture  of  the  nympha,  was  perceived  first  in  perineo,  but  soon  occupied  all 
the  left  labium,  which  was  enormously  distended.  The  pain  at  first  was  so  great 
as  to  cause  syncope.  The  parts  sloughed,  and  discharged  pus  and  clotted  blood. 
Bark  was  given,  and  she  got  well.    Lond.  Med.  Journ.  Vol.  IX.  p.  119. 

t  Vide  case  by  Dr.  Maitland,  in  Med.  Comment.  Vol.  VI.  p.  95. — Dr.  Perfect 
relates  a  case,  where  it  burst  itself  before  the  child  was  born,  and  discharged 
much  blood.  Vol.  II.  p.  63. — In  another,  which  ended  fatally,  the  tumour  burst 
after  deliver}',  and  discharged  five  pounds  of  blood.  Vide  Plenk  Elementa,  p. 
111.— Case  by  M.  Sedillot,  in  Recueil  Period.  Tom.  I.  p.  260. 

*  Vide  cases  by  Dr.  Macbride  in  Med.  Obs.  and  lnq.  Vol.  V.  p.  89. 

§  In  Mr.  Blagden's  case,  related  by  Dr.  Baillie,  the  woman  soon  after  delivery 
had  violent  bearing-down  pains,  as  if  another  child  were  to  be  born.  A  mon- 
strous swelling  appeared  in  the  right  labium,  extending  to  the  perineum.  A 
large  incision  was  made,  which  did  not  heal  till  the  21st  day.  Med.  and  Physical 
Journal.  Vol.  It.  p.  42. 

II  Vide  Fichet  de  Flechy,  Observ.  p.  375.  The  patient  was  cured  by  introduc- 
ing a  compress  into  the  vagina,  and  dressing  the  sore  with  digestive  ointment. 

II  Le  Dran  relates  a  case,  where  above  20  ounces  of  blood  were  evacuated  by 
incision.    Consultations,  p.  413. 


61 

or  be  punctured,  the  previous  inflammation  may  close  the  vessels 
so  as  to  prevent  hemorrhage ;  but  if  it  do  not,  the  vagina  is  to  be 
gently  filled  with  a  soft  cloth  to  prevent  the  fluid  from  extending 
along  the  sides  of  the  pelvis.  A  compress  is  also  to  be  firmly  re- 
tained externally,  to  check  all  hemorrhage  from  the  aperture.  If 
inflammation  run  high,  it  is  to  be  abated  by  the  usual  means. 

§  9.  DISEASES  OF  THE  CLITORIS. 

The  clitoris  may  become  scirrhous,  and  even  be  affected  with 
cancerous  ulceration.  In  this  disease,  it  is  generally  thickened, 
enlarged,*  and  indurated,  and  the  patient  complains  of  consider- 
able pain.  Presently  ulceration  takes  place  and  fungus  shoots  out. 
In  no  case  of  this  kind  that  I  have  met  with,  has  an  operation  been 
submitted  to ;  and,  indeed,  unless  the  whole  of  the  diseased  part 
can  be  removed,  we  must  be  satisfied  with  palliating  symptoms. 
In  one  case,  however,  related  by  Kramer,f  where  the  clitoris  was 
enlarged,  widi  cauliflower-like  excrescences,  and  the  right  nym- 
pha  indurated,  the  parts  were  successfully  removed  by  the  knife, 
after  failing  with  the  ligature,  which  produced  insupportable  pain. 

The  clitoris  sometimes  becomes  preternaturally  elongated ;  and 
if  this  take  place  in  infancy,  and  be  accompanied  with  imperfect 
or  confused  structure  of  the  other  parts,  the  person  may  pass  for 
an  hermaphrodite.J     This  is  said  to  be  most  frequent  in  warm 

*  Mr.  Simmons  cut  off' a  clitoris,  which  formed  a  tumour  nine  inches  in  length, 
and  fourteen  in  circumference,  at  the  largest  end.  The  circumference  of  the 
stem  was  five  inches.     Med.  and  Phys.  Journal,  Vol.  V.  p.  1. 

f  Schmucker's  Miscel,  Surg.  Essays,  art.  XXXIII. 

*  Upon  this  subject,  see  Arnaud  on  Hermaphrodites. 

In  a  child  aged  three  years,  I  found  the  mens  veneris  prominent,  and  as  well 
as  the  labia,  covered  with  a  considerable  quantity  of  red  hair.  The  labia  were 
large  and  thick,  like  those  of  a  grown  woman,  but  shorter.  Their  inner  surface 
was  white  and  rugous,  until  near  the  orifice  of  the  vagina,  where  the  skin  was  red. 
At  the  top  the  labia  divaricated,  and  showed  a  large  clitoris,  which  hung  down 
like  the  penis ;  it  was  upwards  of  an  inch  long,  and  about  half  an  inch  in  diameter, 
and  furnished  with  a  thick  wrinkled  prepuce.  It  had  a  distinct  glans.at  the  end 
of  which  was  observed  something  like  a  perforation;  but  on  raising  it  up,  this 
was  seen  to  be  only  the  extremity  of  a  deep  sulcus,  which  extended  all  the  way 


m 

climates ;  and  in  these,  extirpation  is  sometimes  performed.  Hal- 
ler  assigns  a  cause  for  the  enlargement. 

§  10.  DISEASES  OF  THE  HYMEN. 

The  most  frequent  disease  of  the  hymen  is  imperforation ;  in 
consequence  of  which  the  menses  are  retained,*  the  uterus  is  dis- 
tended, and  the  orifice  of  the  vagina  protruded,  so  as  sometimes 
to  resemble  polypus  or  a  prolapsus  uteri  ;f  or  it  becomes  fretted 
and  covered  with  scabs.  Even  the  perineum  may  be  stretched, 
as  if  the  head  of  a  child  rested  on  it.  J  Menstruation  is  generally 
painful,  and  the  uterus  becoming  enlarged,  contraction  at  last  takes 
place,  and  pains  like  those  of  labour  come  on,  especially  about  the 
menstrual  period  ;^  such  a  case,  may,  therefore,  by  inattention,  be 
mistaken  for  parturition.  j|     The  sufferings  of  the  patient  are,  in 

to  the  urethra,  or  orifice  of  the  vagina.  It  resembled  the  male  urethra  slit  up. 
The  sides  of  this  were  formed  by  the  nymphx.  A  little  before  the  orifice  of  the 
urethra,  there  was  a  longitudinal  eminence,  like  the  veru  montanum.  The 
vagina  was  shut  up  by  the  hymen.  The  uterus  was  large  like  that  of  a  girl  of 
fourteen  years  of  ag-e,  and  was  shaped  like  hers.  The  ovaria  were  of  corres- 
ponding size  ;  one  of  them  lay  on  the  psoas  muscle,  the  other  was  loose  in  the 
pelvis.  The  tubes  were  fimbriated  at  (he  extremity,  but  in  their  course  were 
knotted  and  serpentine,  like  the  commencement  of  the  vas  deferens.  The  ute- 
rus was  very  vascular,  and  had  an  inflamed  appearance.  Its  mouth  was  appa- 
rently impervious. 

In  a  male  child  that  I  lately  saw,  the  external  parts  resemble  those  of  the  fe- 
male. The  scrotum  is  cleft  like  the  vulva,  the  penis  consists  only  of  corpora 
cavernosa,  and  the  urethra  opens  between  the  labia  formed  by  the  scrotum. 

*  The  same  effect  may  be  produced,  by  a  continuation  of  the  skin  being  ex- 
tended over  the  parts.  It  must  be  cut  up.  See  a  case  by  M.  Larrey,  in  Uapport 
General  de  la  Societe  Philomatique,  Tom.  II.  p.  86. 

f  Vide  case  of  a  patient  of  Dr.  Chamberlain's,  in  Cowper's  Anatomy. — Case 
by  Mr.  Fryer,  in  Med.  Facts  and  Obs.  Vol.  VIII.  p.  132. 

£  Case  by  Mr.  Sherwin,  in  Med.  Ilecords,  &c.  p.  279. 

§  Case  by  Mr.  K?jymer,  in  Med.  Annals,  Vol.  VI.  p.  347.  By  Mr.  Eason,  in 
Med.  Comment.  Vol.  II.  p.  187.  and  a  variety  of  other  cases.  This,  in  every  in- 
stance 1  have  known,  has  been  the  greatest  complaint. 

j|  Dr.  Smellie  candidly  acknowledges,  that  in  one  instance  he  took  the  protru- 
sion of  the  hymen  for  the  membranes  of  the  ovum  forced  down  by  labour  pains. 
These  pains  were  accompanied  with  suppression  of  urine.  He  let  out  about  two- 
quarts  of  blood.     Coll.  I.  n.  i.  c.  6. 


63 

some  instances,  increased  by  the  addition  of  suppression  of  urine,* 
or  pain  in  passing  the  f«ces,f  or  convulsions.J  Imperforated  hy- 
men is  by  no  means  uncommon,  and  the  treatment  is  very  simple, 
for  the  part  is  easily  divided.^  The  retained  fluid  is  thus  evacu- 
ated, sometimes  in  very  great  quantity.  It  has  very  rarely  the  ap- 
pearance of  blood,  being  generally  dark  coloured,  and  pretty  thick, 
or  even  like  pitch.  Febrile  and  inflammatory  symptoms  may  follow 
the  operation.  || 

The  hymen  is  sometimes  perforated  as  usual,  but  very  strong, 
so  as  to  impede  the  sexual  intercourse;  yet  in  those  cases  impreg- 
nation has  taken  place,  and  the  hymen  has  been  torn,1T  or  cut  in 
the  act  of  parturition.  Conception  may  take  place,  although  the 
hymen  be  imperforated.** 

*  In  a  case  related  by  Benevoli,  the  belly  was  very  much  swelled,  and  the 
urine  suppressed.  He  attempted  to  pass  the  catheter,  but  without  success.  Next 
day  he  repeated  his  endeavour,  and  pushing  with  more  force  than  prudence, 
considering  his  object,  he  ruptured  the  hymen,  and  immediately  a  great  quan- 
tity of  dark  matter  was  evacuated,  even  to  the  extent  of  32  pints. — See  also  Mr. 
Fryer's  case. — Mr.  Warner  relates  the  case  of  a  little  girl,  where  the  hymen  was 
continued  halfway  over  the  orifice  of  the  urethra.  The  effects  were  at  first  at- 
tributed to  stone  in  the  bladder;  but  the  nature  of  the  case  being  made  out,  she 
was  cured  by  dividing  the  hymen.     Cases,  p.  75. 

f  In  a  case  by  Mr.  Bardy,  the  patient,  who  was  15  years  of  age,  had  every 
month,  for  some  days,  pain  in  the  uterine  region.  The  external  parts  were  great- 
ly protruded  and  stretched  as  in  labour,  and  the  nymphse  formed  merely  two 
lines.  The  anus  was  thrust  backward  and  distended,  and  she  passed  the  urine 
and  fieces  with  great  pain  ;  the  hymen  from  irritation  was  covered  with  scab,  the 
health  had  suffered.  Six  pounds  of  thick  gelatinous  matter  were  evacuated  by 
incision.     Med.  and  Chir.  Review  for  September,  1807. 

i  Vide  Case  by  Mr.  Eynney,  in  Med.  Comment.  Vol.  III.  p.  194. 

§  In  Mr.  Fynney's  case,  the  part  to  be  divided  was  very  thick ;  and  in  Dr. 
M'Cormick's  case,  the  vagina  seemed  to  be  in  part  impervious.  Med.  Comment. 
Vol.  II.  p.  188. — In  general  the  membrane  is  thin. 

i  Vide  Mr.  Kiven's  case,  in  Med.  Comment.  Vol.  IX.  p.  330.  The  symptoms 
gradually  abated. 

r  M.  liaudelocque  mentions  an  instance  where  the  hymen  resisted,  for  half  an 
Lour,  the  strong  action  of  the  uterus.    Note  to  section  341. 

**  Vide  Ambrose  Pare,  Hildanus,  cent.  HI.  ob.  60. — Buysch,  ob.  22. — Mau- 
riceau,  ob.  439.  In  a  case  lately  published  by  Champion,  the  urethra  was  greatly 
dilated,  and  had  served  as  a  substitute  for  the  vagina,  notwithstanding  which  the 
female  became  pregnant,  and  was  delivered  by  dividing  the  hymen.  Jour,  do 
Med.  T.  LXVIH.  p.  84. 


64 

When  the  hymen  is  lorn  in  coitu,  some  blood  is  evacuated, 
which,  in  many  countries,  is  considered  as  a  mark  of  virginity. 
But  as  even  the  presence  or  absence  of  a  hymen  cannot  be  looked 
upon  as  affording  any  certain  proof  relative  to  chastity,  this  test 
must  be  considered  as  altogether  doubtful.  When  the  hymen  is 
ruptured,  and  there  is  an  inflammation  about  the  external  parts, 
some  have,  in  cases  of  alleged  rape,  considered  the  crime  as 
proven.  But  whoever  attentively  examines  the  subject  must  admit, 
that  these  are  very  fallacious  marks ;  that  they  may  exist  without 
any  violence  having  been  employed;  and  that  a  woman  may  have, 
if  previously  stupified,  been  violated  without  exhibiting  any  mark 
of  injury.  Practitioners  therefore  ought,  in  a  legal  question  of  this 
nature,  to  be  cautious  how  they  give  any  opinion,  especially  if  they 
have  not  seen  the  person  immediately  after  the  crime  has  been 
committed.* 

§  11.  LACERATION  OF  THE  PEHINJEUM. 

The  perineum  may  be  torn  during  the  expulsion  of  the  head  or 
arms  of  the  child.  In  many  cases,  the  laceration  does  not  extend 
farther  back  than  to  the  anus,  nor  even  so  far.  This  is  a  very  sim- 
ple accident,  and  requires  no  other  management  than  rest,  and  at- 
tention to  cleanliness.  But  as  the  recto-vaginal  septum  is  carried 
forwards  and  downwards,  when  the  perineum  is  put  on  the  stretch 
previous  to  the  expulsion  of  the  head,  it  sometimes  happens,  that 
the  laceration  extends  along  this  septum,  and  a  communication  is 
formed  betwixt  the  rectum  and  vagina.  In  some  cases,  the  sphinc- 
ter ani  remains  entire,  although  the  rectum  be  lacerated ;  in  others 
it  also  is  torn.  This  accident  is  attended  with  considerable  pain 
and  hemorrhage,  and  succeeded  by  an  inability  to  retain  the  faeces, 
which  pass  rather  by  the  vagina  than  the  rectum.  Prolapsus  uteri 
is  also,  in  some  instances,  a  consequence  of  this  laceration.  This 
accident  is  sometimes  produced  by  attempts  to  distend  the  parts 
previous  to  delivery,  or  by  the  use  of  instruments ;  but  it  may  als» 

*  Vtde  Ifcuidelocque,  l'Art,  &e.  sec.  342,  et  Fodere  Med.  Legale.  Toraell.p.  3 


65 

take  place,  even  to  a  great  degree,  in  a  labour  otherwise  natural  and 
easy,  and  in  which  no  attempts  have  been  made  to  accelerate  de- 
livery. The  most  effectual  way  to  prevent  laceration  is  by  sup- 
porting the  perineum  with  the  hand,  when  it  is  stretched,  and  keep- 
ing the  head  from  being  suddenly  forced  out.  When  the  parts 
have  been  actually  torn,  our  first  attention  is  to  be  directed  to  the  re- 
pressing of  the  hemorrhage,  which  is  sometimes  considerable :  and 
this  is  best  effected  by  compression  and  rest,  which  favour  the  for- 
mation of  coagula.  Next,  we  are  to  'consider  how  the  divided  parts 
may  be  united.  Rest,  and  retaining  the  thighs  as  much  together 
as  possible,  together  with  frequent  ablution,  in  order  to  remove  the 
urine,  which  sometimes  for  a  few  days  flows  involuntary,  or  the 
lochia  and  stools,  are  requisites  in  every  mode  of  treatment.  As 
there  is  nothing  in  the  structure  of  the  parts  to  prevent  their  re- 
union, it  has  very  feasibly  been  proposed  to  induce  a  state  of  cos- 
tiveness,  and  prevent  a  stool  for  many  days.  But  with  only  one  or 
two  exceptions,  this  method  has  failed ;  the  subsequent  expulsion 
of  the  indurated  faeces  tearing  open  the  parts,  if  adhesion  had  taken 
place.  An  opposite  practice,  that  of  keeping  the  bowels  open,  and 
the  stools  soft  or  thin,  by  gentle  laxatives,  has  been  much  more 
successful,  the  parts,  in  some  instances,  healing  in  a  few  weeks  j 
and  this  is  the  practice  I  would  recommend  to  be  adopted,  taking 
care,  at  the  same  time,  to  keep  the  parts  in  contact,  by  confining 
the  patient  to  bed,  with  the  thighs  kept  together.  During  this  pe- 
riod, the  stools  are,  at  least  for  a  time,  passed  involuntary ;  but  in 
other  instances,  they  can  from  the  first  be  retained,  if  the  patient 
keep  in  bed.  Sutures  have  been  also  employed,  and  ought  cer- 
tainly at  last  to  be  had  recourse  to,  if  re-union  cannot  otherwise  be 
effected. (p)  The  edges  of  the  divided  parts  must  previously  be 
made  raw.  It  would  appear  that  there  is  no  occasion  for  putting  a 
ligature  in  the  recto-vaginal  septum.  It  is  sufficient  to  place  two 
in  the  perineum.  When  the  sphincter  ani  remains  entire,  but  the 
septum  is  torn,  some  have  considered  it  necessary  to  divide  that 
muscle;  but  others,  with  more  reason,  omit  this  practice.    During 

CpJ  Sutures  should  be  rarely  had  recourse  to,  as  they  occasion  considerable 
irritation,  and  are  liable  to  be  torn,  or  to  slough  out. 

10 


the  cure,  some  introduce  a  canula  into  the  vagina,  to  support  the 
parts,  and  others  apply  compresses  dipped  in  balsams ;  but  it  is  bet- 
ter to  apply  merely  a  pledget,  spread  with  simple  ointment  to  the 
part.  If  the  radical  cure  fail,  the  patient  must  use  a  compress,  with 
a  T-bandage,  if  the  stools  cannot  be  retained.  But  it  sometimes 
happens  that  the  torn  extremity  of  the  rectum,  or  the  anterior  part, 
forms  a  kind  of  flat  valve,  which  rests  on  the  posterior  surface  at 
the  coccyx,  so  that  the  orifice  now  resembles  a  slit,  and  the  faeces, 
unless  very  liquid,  remain  in  the  hollow  of  the  sacrum,  and  do  not 
pass  through  the  valvular  orifice  till  an  effort  be  made  to  expel.* 

§  12.  IMPERFECTION  OF  THE  VAGINA. 

The  vagina  may  be  unusually  small.  I  have  known  it  not  above 
three  inches  long,  and  sometimes  it  is  very  narrow.  The  size,  if 
necessary,  may  be  enlarged  with  a  tent  of  prepared  sponge.f 
Should  pregnancy  take  place  before  it  be  fully  dilated,  we  need  be 
under  no  apprehension  with  regard  to  delivery  ;  for  during  labour, 
or  even  long  before  it,  relaxation;};  takes  place.  Sometimes  the 
vagina  is  wanting  or  impervious,  or  all  the  middle  portion  of  the 
canal  is  filled  up  with  solid  matter.  More  frequently,  however* 
there  is  only  a  firm  septum  stretched  across,  behind  the  situation  of 
the  hymen,  or  higher  up  in  the  vagina ;  and  this^  it  may  be  ne- 
cessary to  divide.     In  some  cases,  there  is  a  great  confusion  of 

*  Upon  this  subject,  vide  La  Motte's  Traite* ;  and  cases  and  observations  by 
Noel,  Saucerote,  Trainel,  and  Sedillot,  in  the  fourth  and  seventh  Vol.  of  the  Ke- 
cueil  Periodique.  Dr.  Denman  mentions  an  instance  where  the  perineum  was 
not  torn  up,  but  perforated  by  the  head.  Both  Petit  and  Gardien  notice  the  fact 
that  the  stools  may  ultimately  come  to  be  retained,  but  do  not  seem  aware  that 
this  depends  on  the  formation  of  a  valve.  They  think  it  owing  to  the  sphincter 
regaining  its  power. 

j-  Vide  Van  Swieten  Comment,  in  aph.  1290. 

$  In  a  case  where  the  vagina  would  not  admit  the  point  of  the  little  finger,  the 
child  was  delivered  after  eighteen  hours  labour.  Plenk  Elementa,  p.  113.  See 
also  Van  Swieten. 

§  This  may  produce  bad  effects,  from  retention  of  the  menses.  M.  Magnan 
relates  the  case  of  a  girl,  aged  22  years,  who  had  been  subject  to  monthly  colics 
and  suppression  of  urine.  An  incision  was  made  through  the  membrane,  and  two 
pounds  of  blood  let  out.    Hist,  de  la  Societe"  de  Med.  pour  1776,  art.  II. 


67 

parts,  and  indeed,  it  is  impossible  to  describe  the  varieties  of  con- 
formation; for  the  vagina  may  follow  a  wrong  course,  or  commu- 
nicate with  the  urethra,  or  the  rectum*  may  terminate  in  the  va- 
gina, &c.     Malformation  does  not  always  prevent  pregnancy  .f 

§  13.  INFLAMMATION  AND  GANGRENE  OF  THE  VAGINA. 

In  consequence  of  very  severe  labour,  inflammation,  followed 
by  gangrene  of  the  vagina,  may  be  produced.  If  the  sloughs  be 
small,  then  partial  contraction  of  the  diameter  of  the  canal  may 
take  place,  and  cause  much  inconvenience  from  retention  of  the 
menses,J  or  during  a  subsequent  labour ;  but  in  this  last  case,  the 
parts  gradually  yield,  and  it  is  seldom  necessary  to  perform  any 
operation  :  the  pain,  however,  is  sometimes  excruciating  till  the 
part  yield.^ 

In  some  instances  the  sloughs  are  so  extensive,  that  the  whole 
vulva  is  destroyed,  or  part  of  the  urethra  and  vagina  come  away, 
or  general  adhesion  takes  place,  leaving  only  a  small  opening, 
through  which  the  urine  and  the  menses  flow.     Should  this,  by 

*  In  this  case  the  faeces  do  not  always  pass  continually.  The  patient  has  been 
known  not  to  have  a  stool  once  in  a  fortnight ;  which  probably  depended  on  the 
faeces  being  indurated,  and  the  communication  small. 

-j-  In  the  33d  Vol.  of  the  Phil.  Trans,  p.  142,  there  is  a  case  related,  where 
there  was  a  kind  of  double  vagina,  separated  by  a  transverse  septum  or  mem- 
brane. The  orifices  were  very  small.  During  labour,  the  pain  was  so  great  as  to 
produce  convulsions.  She  was  delivered,  by  laying  the  two  passages  into  one. 
Chapman  relates  a  case  of  malformation,  where  the  woman  was  impregnated, 
and  in  labour  all  the  forcing  was  felt  at  the  anus.  From  this  an  opening  was 
made  through  into  the  vagina,  and  the  child  was  born  per  anuui.  Portal  men- 
tions a  girl,  who  had  only  a  very  small  aperture  at  the  vulva,  for  the  evacuation 
of  the  urine  ;  the  menses  came  from  the  rectum ;  nevertheless,  she  became  preg- 
nant. Before  delivery,  the  orifice  of  the  vagina  appeared,  and  she  bore  the 
child  the  usual  way.     Precis  de  Chirurgie,  Tom.  II.  p.  745. 

*  Richter  in  Comment.  Gotting.  Tom.  III.  art.  2.  relates  a  case  of  a  girl  aged 
20  years,  who  for  three  years  had  been  subject  to  violent  pains  about  the  sacrum, 
with  tremours  and  syncope  every  month.  The  vagina  was  found  to  be  closed 
at  the  upper  part,  in  consequence,  it  was  imagined,  of  a  variolous  ulcer  in  infancy. 
Fluctuation  was  felt  in  the  vagina,  when  pressure  was  made  with  the  other  hand 
on  the  abdomen.    The  contraction  was  opened,  and  a  quantity  of  blood  let  out, 

§  Harvey,  exercit.  LXXIII.p.  492, 


68 

any  means  be  obstructed,  the  discharges  cannot  take  place ;  and 
sharp  pains,  or  even  convulsions,  may  be  the  consequence.  Some- 
times calculous  concretions  form  beyond  the  adhering  part.* 

Whenever  we  have  reason  to  expect  a  tender  state  of  the  parts 
after  delivery,  we  must  be  exceedingly  attentive  ;  and  if  the  vagina, 
or  any  other  organ,  be  inflamed  or  tender,  we  must  bathe  the  parts 
frequently,  and  inject  some  tepid  water  gently,  to  promote  clean- 
liness. Saturnine  fomentations  and  injections  are  often  of  service, 
but  they  must  not  be  thrown  high.  The  urine  must  be  regularly 
evacuated ;  and  should  a  slough  take  place,  we  must,  by  proper 
dressings,  or  the  use  of  a  thick  bougie,  prevent  coalescence  of  the 
vaginal  canal.f 

Abscesses  and  sinuses  connected  with  the  vagina,  must  be 
treated  on  the  general  principle  of  surgery ;  but  it  is  proper  to 
mention  that  sometimes  the  orifice  of  the  sinus  is  excessively  ten- 
der to  the  touch,  insomuch  as  almost  to  produce  syncope.  In  all 
cases  of  extreme  sensibility  of  this  canal,  it  ought  to  be  carefully 
examined,  and  the  painful  spot  may  point  out  the  seat  of  the  dis- 
ease. The  sinus  should  be  laid  open,  and  hemorrhage  prevented 
by  the  injection  of  cold  water,  or  insertion  of  lint,  wet  with  cold 
water. 


§  14.  INDURATION,  ULCERATION  AND  POLYPI. 

The  vagina  may  be  contracted  by  scirrhous  glands  in  its  course, 
or  induration  of  its  parietes,  which  become  thick  and  ulcerated, 
and  communicate  with  the  bladder  or  rectum.  This  disease  is 
generally  preceded  by,  or  accompanied  with,  scirrhous  uterus, 
and  requires  the  same  treatment. 

Foreign  bodies  in  the  vagina  produce  ulceration,  and  fungous 
excrescences.     The  source  of  irritation  being  removed,  the  parts 

*  Vide  Puzos  Traite,  p.  140. — Case  by  Mr.  Purton,  in  Med.  and  Phys.  Jour. 
Vol.  VI.  p.  2. 

f  In  some  parts  of  Africa,  the  vagina  is  made  impervious,  in  order  to  prevent 
coition.  This  operation  is  generally  performed  betwixt  the  age  of  eleven  and 
twelve  years.    Brown's  Travels,  p.  349. 


69 

heal;  but  we  must,  by  dressing  and  injections,  prevent  coales- 
cence. 

Polypous  tumours  may  spring  from  the  vagina,  and  are  to  be 
distinguished  from  polypus  of  the  uterus  by  examination.  The 
diagnosis  betwixt  polypus  and  prolapsus,  or  inversio  uteri,  will  be 
afterwards  pointed  out.  The  cure  is  effected  by  the  application 
of  the  ligature  more  solito. 

§  15.  INVERSION. 

The  vagina  may  be  inverted  or  prolapsed,  without  any  material 
change  in  the  state  of  the  womb,  and  without  symptoms  of  uterine 
irritation,  farther  than  slight  pain  in  the  back,  and  a  little  mucous 
discharge.  We  find  a  fleshy  substance  protruding  at  the  back 
part  of  the  vulva,  having  an  opening  before  leading  into  the  vagina. 
If  the  procidentia  be  considerable,  the  rectum  is  carried  forward, 
and  in  every  instance  is  relaxed.  At  first  the  tumour  is  soft ;  but 
after  some  time,  if  the  part  has  been  irritated,  it  may  inflame,  in- 
durate, or  ulcerate.  It  is  cured  by  strict  attention  to  the  state  of 
the  bowels,  thereby  preventing  accumulation  in  the  rectum,  by 
astringent  injections  into  the  vagina,  the  cold  bath,  the  internal  use 
of  tincture  of  kino,  and,  if  these  fail,  by  a  globe  pessary,  or  a 
spring-bandage  similar  to  that  employed  for  prolapsus  ani,  or  by 
pregnancy  ;  but  it  sometimes  returns  after  delivery.* 

§  16.  WATERY  TUMOUR. 

Water  sometimes  passes  down  from  the  abdominal  cavity,  be- 
twixt the  vagina  and  rectum,  protruding  the  posterior  surface  of 
the  vagina  in  the  form  of  a  bag ;  and  the  accumulation  of  water  in 
the  cavity  of  the  pelvis  is  sometimes  so  great  as  to  obstruct  the 
flow  of  the  urine,  or  produce  strangury.     When  the  person  lies 

*  Burton  relates  a  case,  where  the  prolapsed  vagina  was  mistaken  for  part  of 
the  placenta,  and  rudely  pulled  away,  by  which  the  vagina  and  bladder  were 
torn.     System,  p.  170. 

Stollers  relates  a  case,  where  this  was  complicated  with  calculi.  These  being 
removed,  the  parts  were  reduced,  and  a  cure  obtained.    Cases,  Oba.  2. 


70 

down,  the  swelling  disappears.  If  large,  a  candle  held  on  the  op- 
posite side,  sometimes  shows  it  to  be  transparent ;  and  in  every 
case,  fluctuation  may  be  felt.  As  this  symptom  is  connected  with 
ascites,  the  usual  treatment  of  that  disease  must  be  pursued,  and,  if 
necessary,  the  water  may  be  drawn  off  by  tapping  the  abdomen,  or 
rather  by  piercing*  the  tumour,  which  is  to  be  rendered  tense,  by 
pressing  it  with  the  finger. 

§  17.  HERNIA. 

Sometimes  the  intestine  passes  down  betwixt  the  vagina  and 
rectum,  forming  perineal  hernia,  or  protrudes  either  at  the  lateral 
or  posterior  part  of  the  orifice  of  the  vagina,  like  the  watery  tu- 
mour ;  but  is  distinguished  from  it  by  its  firmer  and  more  doughy 
feel,  and  by  the  manner  in  which  it  can  be  returned.  By  handling 
it,  a  gurgling  noise  may  be  heard,  and  sometimes  indurated  faeces 
may  be  felt.  As  the  os  uteri  is  pushed  forward,  and  the  posterior 
part  of  the  vagina  occupied  by  the  herniary  tumour,  this  complaint 
may  put  on  some  appearance  of  retroverted  uterus.     A  case  of 

*  Mr.  Henry  Watson,  in  the  Med.  Communications,  Vol.  I.  p.  162,  called  the 
attention  of  practitioners  to  this  disease.  In  a  case  he  relates,  he  drew  off  in  the 
month  of  June,  four  gallons  of  fluid,  by  tapping  the  vagina;  and  immediately 
after  this  she  passed  the  urine  freely,  which  she  could  not  do  before.  She  re- 
quired again  to  be  tapped  in  two  months,  and  died  in  November.  The  left  ova- 
rium was  found  to  be  converted  into  a  cyst  about  the  size  of  a  sow's  bladder,  but 
it  had  not  been  touched  by  the  trocar.  In  one  case,  he  punctured  with  a  lancet 
instead  of  a  trocar,  but  this  was  succeeded  by  troublesome  hemorrhage.  The 
good  effects  of  tapping  are  also  seen  in  a  case  related  by  Mr.  Coley,  in  Med.  and 
Ph\s.  Journal,  Vol.  VII.  p.  412.  In  this  two  gallons  of  water  were  drawn  off, 
and  she  continued  well  for  five  months,  after  which  dropsical  symptoms  returned, 
and  although  diuretics  gave  her  some  relief,  yet  she  was  at  last  cut  off.  In  the 
case  of  Mrs.  Jarritt,  related  by  Sir  W.  Bishop,  in  Med.  Commun.  Vol.  II.  p.  360, 
pain  was  felt  in  the  right  side  of  the  belly,  after  parturition,  accompanied  with 
tumefaction.  In  two  years  the  vagina  became  prolapsed,  the  tumour  being  four 
inches  in  diameter  The  tumour  was  punctured  twice;  the  first  time  46  pints, 
the  second  51,  were  drawn  off.  Diuretics  had  no  effect.  In  a  case  related  by 
Dr.  Denman,  the  woman  was  pregnant,  and  no  operation  was  performed.  On 
the  fourth  day  after  her  delivery,  after  a  few  loose  stools,  she  expired.  Introd. 
Vol  I.  p.  150. 


71 

tins  kind  is  mentioned  by  Dr.  John  Sims,  in  Mr.  Cooper's  work 
on  Hernia.  This  complaint  is  frequently  attended  with  a  bearing- 
down  pain ;  and  on  this  account,  as  well  as  from  its  appearance, 
it  has  also  been  mistaken  for  prolapsus  uteri.  Sometimes  the  tu- 
mour does  not  protrude  externally;  but  symptoms  of  strangulated 
hernia  may  appear,  the  cause  of  which  cannot  be  known,  unless 
the  practitioner  examine  the  vagina.  In  a  case  occurring  to  Dr. 
Maclaurin,  and  noticed  by  Dr.  Denman,  the  patient  died  on  the 
third  day,  and  the  disease  was  not  discovered  till  the  body  was 
opened.  Should  a  woman  have  vaginal  hernia  during  pregnancy, 
we  must  be  careful  to  return  it  before  labour  begin,  for  the  intes- 
tine may  become  inflamed,  and  the  faeces  obstructed,  by  the  head 
entering  the  pelvis ;  or  the  labour  itself,  if  the  head  cannot  be 
raised  and  the  intestine  returned,  may  be  impeded  so  much  as  to 
require  the  use  of  instruments.  Vaginal  hernia  requires  the  use 
of  a  pessary,  or  a  spring-support. 

The  rectum  sometimes  protrudes  into  the  vagina,  and  always 
does  so  more  or  less  in  an  inversio  vaginae.  This  is  remedied  by 
the  globe  pessary,  after  all  the  indurated  faeces  have  been  removed. 
The  farther  accumulation  is  prevented  by  laxatives. 

§  18.  ENCYSTED  TUMOUR  AND  VARICES. 

Indolent  abscess,  or  encysted  tumours,  may  form  betwixt  the 
vagina  and  neighbouring  parts.  These  are  distinguished  from 
hernia  and  watery  tumours  by  being  incompressible,  and  not  dis- 
appearing by  change  of  posture.  The  history  of  the  disease 
assists  the  diagnosis,  and  examination  discovers  the  precise  seat 
and  connections  of  the  tumour,  though  it  cannot  with  certainty 
point  out  the  nature  of  the  contents.  These  tumours  seldom  afford 
obstinate  resistance  to  delivery;  by  degrees  they  yield  to  the  pres- 
sure of  the  head,  but  sometimes  they  return  after  delivery.  The 
treatment  is  similar  to  that  required  in  other  cases  of  tedious  la- 
bour, and  the  tumour  must  be  opened,  if  we  cannot  deliver  the 
woman  otherwise,  with  safety  to  the  child.  Even  in  the  unim- 
pregnated  state,  if  it  cause  irritation,  or  if  the  bulk  of  the  tumouv 


12 

be  so  great  as  to  impede  the  evacuation  of  urine  or  feces,  an  open- 
ing must  be  made.  After  delivery,  in  those  cases  where  no  ope- 
ration is  performed,  the  tumour  sometimes  inflames  and  indurates 
even  so  low  as  the  perineum.  Friction  on  the  perineum,  has,  in 
these  circumstances,  done  good. 

Varicose  tumours,  of  a  knotted  form,  disappearing  or  becom- 
ing slack  by  pressure,  and  aneurismal  tumours,  distinguishable 
by  their  pulsation,  may  form  about  the  vagina,  and  ought  not  to 
be  interfered  with,  except  by  supporting  them  with  a  globe  in  the 
vagina. 

§  19.  SPONGOID  TUMOUR. 

A  very  dreadful  disease,  which  I  have  called  spongoid  tumour, 
may  form  either  within  the  pelvis,  or  about  the  hip-joint,  or  tube- 
rosity of  the  ischium,  and  spread  inwards,  pressing  on  the  bladder 
and  rectum,  sometimes  so  much  as  to  require  the  use  of  the  cathe- 
ter. We  recognise  the  disease,  by  its  assuming  very  early  the 
appearance  of  a  firm  elastic  tumour,  as  if  a  sponge  were  tied  up 
tightly  in  a  piece  of  bladder.  Presently  it  becomes  irregular,  and 
the  most  prominent  parts  burst,  discharging  a  red  fluid,  which  is 
succeeded  by  fungous  ulceration.  But  I  have  never  known  it  pro- 
ceed to  this  last  stage  within  the  pelvis.  I  know  of  no  remedy, 
and  would  dissuade  from  puncturing,  except  in  the  very  last  ex- 
tremity.    1  have  never  met  with  a  case  where  it  was  necessary. 


§  20.  ERYSIPELATOUS  INFLAMMATION. 

The  orifice  of  the  vagina,  together  with  the  labia,  and  indeed 
the  whole  vulva  may  be  affected  by  erysipelatous  inflammation. 
This  appears  under  two  conditions:  1st,  it  may  originate  in  the 
vulva,  and  spread  inwards,  even  to  the  uterus;  or,  2dly,  it  may 
begin  in  the  womb,  and  extend  outwards.  The  parts  are  tumid, 
painful,  and  of  a  dark  red  colour.  The  second  affection  is  most 
frequent  after  parturition;  but  the  first  may  occur  at  any  age,  and 
under  a  variety  of  circumstances.     It  may  be  confined  to  the  ex- 


73 

ternal  parts  alone,  or  it  may  quickly  spread  within  the  pelvis,  and 
destroy  the  patient;  for  this  disease  generally  terminates  in  gan- 
grene. Vigarous*  says,  this  state  may  be  distinguished  from  ab- 
scess of  the  labium,  by  both  labia  being  equally  affected.  The 
general  history  of  the  case,  and  proper  examination,  will  point  out 
the  difference.  When  the  disease  is  confined  to  the  external  parts, 
we  may  hope  for  a  cure,  and  even  for  the  preservation  of  the  parts, 
by  giving  early,  bark  and  opium  internally,  and  applying  to  the 
surface,  pledgits  dipped  in  weak  solution  of  sulphate  of  zinc,  with 
the  addition  of  a  tenth  part  of  camphorated  spirit  of  wine.  When 
this  application  gives  continued  pain,  fomentations  with  milk  and 
water,  or  with  decoction  of  chamomile  flowers  may  be  substi- 
tuted. 

A  highly  sensible  or  inflamed  state  of  the  parts  may  occur  in 
nymphomania,  or  libidinous  madness,  either  as  a  primary  or  secon- 
dary affection;  and  should  the  patient  die  under  the  disease,  the 
parts  are  generally  found  black.  The  tepid  bath  and  fomentations 
give  relief,  and  sometimes  saturnine  applications  are  beneficial. 
The  acetite  of  lead  has  also  been  given  internally.  If  the  patient 
be  feverish,  she  ought  to  be  blooded,  and  have  cathartics  admin- 
istered, and  be  put  on  spare  diet.  Nauseating  doses  of  tartar  emetic, 
or  full  doses  of  the  medicine,  given  so  as  to  operate  briskly,  are  of 
service,  especially  if  followed  by  sleep.  Strict  and  prudent  atten- 
tion must  be  paid  to  the  mind. 

A  constant  heat  and  tenderness  of  the  parts,  if  not  occasioned 
by  uterine  disease,  may  be  relieved  by  bathing  with  solution  of 
sulphate  of  zinc,  and  using  laxatives. 

Prurigo  is  often  symptomatic  of  disease  in  the  uterus,  or  irrita- 
tion in  the  neighbouring  parts ;  and  in  these  cases  can  only  be  re- 
moved by  acting  on  the  cause.  When  it  is  not  dependent  on  any 
evident  local  disorder,  it  is  allayed  or  cured  by  keeping  the  bowels 
open,  avoiding  stimulants,  and  applying  to  the  affected  parts  ung. 
hyd.  nit.  or  bathing  frequently  with  very  weak  solutions  of  oxymu- 
riate  of  mercury,  or  the  same  salt  mixed  with  lime  water,  or  lime 
water  alone,  or  solution  of  sulphate  of  zinc  alone,  or  with  laudanum. 

*  Maladies  ties  Femmes,  Tome  IT.  p.  169 
11 


74 

&c.     This  affection  may  attend  the  early  period  of  pregnancy,  or 
the  cessation  of  menstruation. 

Prurigo  affecting  the  anus  alone,  or  along  with  the  pudendum, 
may  arise  from  ascarides  or  other  removable  irritations;  but  in  el- 
derly females  this  symptom  should  always  lead  to  an  examination 
of  the  rectum,  for  it  often  attends  stricture  or  alteration  of  the  in- 
testine, which  should  be  early  attacked  by  suitable  means.  So  far 
as  itching  and  local  uneasiness  require  prescription,  nothing  often 
succeeds  better  than  a  suppository  consisting  of  three  grains  of  ex- 
tract of  hemlock  and  one  of  opium. 

§  21.  FLUOR  ALBUS. 

The  vagina  is  always  moistened  with  a  fluid,  secreted  by  the  la- 
cunae on  its  surface.  To  this  is  added  the  secretion  from  the  glands 
of  the  cervix  uteri,  and  the  serous  exhalation  from  the  membrane 
of  the  uterine  cavity.  Naturally,  the  balance  between  secretion 
and  absorption  is  such,  that  except  on  particular  occasions,  no  fluid 
is  discharged  from  the  vagina.  But  in  a  diseased  state,  the  quan- 
tity of  the  secretion  is  greatly  increased,  and  the  discharge,  whether 
proceeding  solely  from  the  vagina,  or  partly  also  from  the  womb, 
receives  the  name  of  fluor  albus,  leucorrhcea.  Some  confine  the 
term  strictly  to  a  discharge  from  the  inner  surface  of  the  womb; 
and  in  order  to  determine  whether  the  secretion  proceeds  from  the 
uterus  or  not,  it  has  been  proposed  to  stuff  the  vagina  completely 
for  some  time,  and  then  inspect  the  plug,  to  ascertain  whether  that 
part  corresponding  to  the  os  uteri  be  moistened.*  But  this  test  is 
not  satisfactory,  and  will  seldom  be  submitted  to. 

When  the  discharge  proceeds  from  the  womb,  it  sometimes  in- 
jures the  function  of  that  organ  so  much,  or  is  dependent  on  a  cause 
influencing  the  uterus  so  strongly,  as  to  interfere  with  menstru- 
ation, either  stopping  it  altogether,  or  rendering  it  too  abundant  or 
irregular  in  its  appearance  ;  and  in  such  cases,  the  woman  seldom 
conceives.  Very  frequently,  however,  the  menses  do  continue 
pretty  regularly ;  and  in  those  cases,  the  other  discharge  disappear? 

*  Chambon,  Malacl.  des  Fillcs,  p.  104. 


75 

during  the  flow  of  the  menses,  but  is  increased  for  a  little  before 
and  after  menstruation.  When  the  menses  are  obstructed,  it  is  not 
uncommon  for  the  fluor  albus  to  become  more  abundant,  and  to  be 
attended  with  more  pain  in  the  back,  about  the  monthly  period. 
In  such  cases  it  has  been  thought  that  the  leucorrhoea  served  as  a 
substitute  for  menstruation,  and  that  it  was  dangerous  to  check  it. 
If  a  woman,  who  has  uterine  leucorrhoea  conceive,  the  discharge 
stops,  but  a  vaginal  secretion  is,  on  the  contrary,  not  unfrequently 
increased.  This  it  has  been  thought  dangerous  to  check  suddenly, 
but  it  ought  not  to  be  allowed  to  continue  profuse,  as  it  causes 
abortion. 

Fluor  albus  may  occur  in  two  very  different  states  of  the  consti- 
tution, either  as  an  effect  of  these,  or  produced  in  them  by  acciden- 
tal causes.  These  are,  a  state  of  plethora,  or  disposition  to  vas- 
cular activity,  and  a  state  of  debility.  The  one  is  marked  by  a  full 
habit,  a  good  complexion,  and  a  clear  healthy  skin.  The  other  by 
a  pale  countenance,  a  sallow  surface,  a  feeble  pulse,  and  generally 
a  spare  habit.  The  one  is  attended  with  vertigo,  or  disease  pro- 
duced by  fulness.  The  other  by  dyspepsia,  palpitation,  and  those 
complaints  which  are  connected  with  debility. 

The  discharge  is  produced  either  by  the  lacunae  of  the  vagina, 
or  the  glandular  and  exhalent  apparatus  of  the  uterus.  The  most 
ample  and  the  most  frequent  source  is  from  the  vagina.  The  dis- 
charge itself  may  consist  simply  of  the  natural  mucus  of  the  part 
increased  in  quantity,  in  which  case  it  is  glairy  and  transparent;  or 
it  may  be  so  far  changed  as  to  become  opaque,  and  white  like  milk, 
which  is  particularly  the  case  when  the  organs  of  secretion  of  the 
upper  part  of  the  vagina  and  cervix  uteri  are  affected,  or  it  may  be 
purulent.  These  may  all  occasionally  be  mixed  with  a  little  blood 
from  the  uterine  vessels,  if  there  be  a  tendency  to  monorrhagia,  but 
not  otherwise,  unless  there  be  organic  disease.  In  those  cases 
where  the  discharge  is  yielded  by  diseased  structure,  it  is  modified 
by  the  nature  of  that  structure,  and  by  the  existence  of  ulceration 
and  erosion.  When  it  proceeds  from  the  morbid  part  itself,  ami 
not  from  the  irritating  effects  of  that  part  on  the  vagina,  by  sym- 
pathy, it  is  generally  foetid,  and  purulent,  often  of  a  dark  colour 


76 

mixed  with  blood,  and  alternated  by  uterine  hemorrhage.  There 
is  often  heat  about  the  parts,  and  other  symptoms  of  disease.  In 
all  ambiguous,  and  in  every  chronic  case,  it  is  necessary  to  ex- 
amine carefully  the  state  of  the  uterus  and  vagina. 

We  must  bear  in  mind  that  fluor  albus  may  be  caused  by 
local  irritation,  including  the  effect  of  diseased  structure,  or  mis- 
placed uterus;  by  a  state  of  increased  vascular  action  ;  and  by  de- 
bility, either  preceded  by  increased  action,  or  directly  produced 
by  weakening  causes. 

Fluor  albus  is  usually  accompanied  with  pain,  and  sense  of 
weakness  in  the  back.  The  functions  of  the  digestive  organs  are 
always  ultimately  injured,  and  in  those  women  who  are  of  a  weak 
habit,  they  are  impaired  from  the  first.  In  them  the  discharge  adds 
greatly  to  the  debility,  and  all  the  diseases  arising  from  that  state 
increase,  such  as  indigestion,  derangement  of  the  hepatic  secre- 
tion, torpor  of  the  bowels,  palpitation,  swelling  of  the  feet,  he.  In 
the  more  plethoric  patients,  the  debilitating  effects  are  longer  of 
appearing,  but  they  are  not  exempted  from  affection  of  the 
stomach. 

Fluor  albus  may  be  excited  by  the  presence  of  a  polypus  in 
utero,  or  in  consequence  of  prolapsus  uteri,  or  of  disease  of  the 
womb ;  but  in  such  cases  it  is  symptomatic,  and  is  not  at  present 
to  be  considered.  The  idiopathic  fluor  albus  may  be  produced  by 
various  exciting  causes,  such  as  abortion,  menorrhagia,  frequent 
parturition,  excessive  venery,  cold  or  fatigue  after  a  miscarriage 
or  a  delivery  at  the  full  time,  and  whatever  can  weaken  the  action 
of  the  uterus.*  It  was  at  one  time  supposed,  that  it  might  also  be 
produced  by  a  bad  state  of  the  fluids  of  the  body,  a  bilious  caco- 
chymy,  a  leucophlegmatic  habit,  passions  of  the  mind,  &c.  The 
application  of  cold,  or  rather  circumstances  exciting  irritation  of 
the  vaginal  membrane,  may  produce  it  in  the  same  way  as  they 
produce  catarrh.    Worms  may  cause  it. 

In  treating  fluor  albus,  we  must  consider  whether  it  be  sympto- 
matic of  polypus,  prolapsus,  or  cancer,  &c.  If  it  be  not,  we  have 
then  to  attend  to  the  general  state  of  the  constitution.     Should  the 

*  Chambon,  Mated,  des  Filles,  p.  104. 


77 

patient  be  plethoric,  or  robust,  it  is  necessary,  in  the  first  instance, 
to  diminish  the  fulness  and  activity  of  the  vessels,  by  mild  and 
perhaps,  spare  diet,  by  moderate  doses  of  laxative  medicine,  and 
even,  if  requisite,  by  the  lancet.  Regular  exercise  is,  in  this  view, 
of  benefit,  but  in  all  cases,  fatigue  increases  the  discharge.  Then 
we  give  bitters  with  alkali,  to  improve  the  state  of  the  stomach 
and  bowels,  and  employ  an  injection  of  solution  of  acetite  of  lead, 
which  is  to  be  thrown  three  or  four  times  a  day  into  the  vagina, 
and  this  may  afterwards  be  exchanged  for  one  of  a  more  astringent 
quality.  I  agree  with  those  who  think  that,  in  cases  connected 
with  plethora,  astringent  injections,  especially  if  used  early,  are 
hurtful,  and  may  give  a  disposition  to  uterine  diseases. 

If  the  disease  occur  in  a  weak  habit,  or  if  the  plethoric  state, 
though  it  existed  at  one  time,  have  now  been  removed,  the  inter- 
nal remedies  must  be  more  directly  tonic,  and  injections  of  various 
astringents  must  be  employed;  of  these  the  two  best  are  solution 
of  sulphate  of  alumin,  and  decoction  of  oak  bark.  The  action  of 
cold  and  damp  is  to  be  avoided,  as  these  are  hurtful  in  every  af- 
fection of  mucous  membranes,  whether  chronic  or  acute.  Of  the 
internal  remedies,  some  are  intended  to  act  by  sympathy  on  the 
secreting  parts,  as  emetics,  others  as  general  tonics.  Emetics  are 
of  very  considerable  advantage,  on  account  of  their  operation  on 
the  stomach  and  alimentary  canal,  and  are  accordingly  advised  by- 
most  writers  ;*  but  they  are  not  to  be  repeated,  nor  employed  at 
all,  during  the  existence  of  plethora.  Purges  have  also  been  used,f 
in  order  to  carry  off  noxious  matter ;  but  they  are  only  to  be 
given,  so  as  to  keep  the  bowels  regular,;};  for  brisk  and  repeated 
purging  is  hurtful.^  Tonic  medicines,  and  those  which  improve 
the  action  of  the  chylopoetic  viscera,  such  as  lime  water,  myrrh, 
bark,  steel,  rhubarb,  uva  ursi,  Sic.  are  also  of  much  utility,  and 

*  Smellie,  Vol.  I.  p.  67.— Vigarous,  Tome  I.  p.  261.— Mead,  Med.  Precepts, 
chap.  XIX.  sect.  3d.— Denman,  Vol.  II.  page  104.— See,  also,  Etmuller,  Kive- 
rius,  &c.  &c. 

f  Chambon,  Malad.  des  Filles,  p.  107.— Mead,  Med.  Precepts,  chap.  XIX, 
sect.  3d. 

T  Stoll  Pnelectiones,  Tomus  II.  p.  383. 

4  Vigarous,  Malad.  desFemmes,  Tome  I.  p.  261*. 


78 

along  with  them  we  may,  with  great  advantage,  employ  the  cold 
bath.  Kino  has  been  "advised  by  Vigarous  and  Gardien,  and  when 
astringents  are  proper,  it  may  be  employed  in  the  form  of  tincture. 
The  diet  is  to  be  light  and  nourishing,  and  the  patient  ought  not 
to  indulge  in  too  much  sleep. 

Various  medicines  have  been  proposed  with  a  view  of  acting 
specifically  on  the  secreting  parts,  such  as  cicuta,  balm  of  Gilead, 
diuretic  salts,  calomel,  resins,  cantharides,  electricity,  arnica,  &,c. ; 
but  they  have  very  little  good  effect,  and  sometimes  do  harm.  Of 
all  these,  the  tincture  of  cantharides^J  and  oil  of  turpentine,  by 
exciting  the  uterine  vessels  in  chronic  secretions,  seem  to  be  the 
best,  but  no  internal  medicine  can  be  much  depended  on,  in  this 
view.  By  suckling  a  child,  the  discharge  has  in  some  instances 
been  removed.  Plasters  and  liniments  have  been  applied  to  the 
back,  and  sometimes  relieve  the  aching  pains.  Opiates  are  occa- 
sionally required,  on  account  of  uneasy  sensations.  When  it  has 
succeeded  to  some  eruptive  disease,  sulphureous  preparations 
have  been  advised. 

When  the  discharge  is  very  opaque,  and  attended  with  consi- 
derable pain  in  the  back  and  loins,  there  is  reason  to  think  that  the 
cervix  uteri  is  in  a  state  of  irritation,  and  by  examination  it  may 
be  found  tender  to  the  touch,  and  the  mouth  soft  and  enlarged  a 
little.  This  state  does  not  constitute  disease  of  structure,  though 
it  may  lead  to  it,  but  it  consists  merely  in  an  affection  of  the  glands. 
It  is  to  be  managed  in  the  first  stage,  by  the  warm  sea-water  hip- 
bath, mild  mercurial  preparations,  laxatives,  and  avoiding  all  irri- 


(~gj  Mr.  Roberton,  a  surgeon  of  Edinburgh,  in  a  paper  published  in  the  Lon- 
don Medical  and  Physical  Journal,  Vol.  XV.  and  also  in  a  distinct  work  on  the 
Effects  of  Cantharides,  when  taken  internally,  strongly  recommends  this  pow- 
erful article  of  the  materia  medica,  in  obstinate  cases  of  Leucorrhoea ;  and  re- 
cites a  number  of  instances,  in  which  it  appears  to  have  produced  the  best  effects. 
In  his  exhibition  of  this  medicine,  he  generally  begun  with  about  gij  or  gijss 
of  the  tincture,  in  3VJ  of  water  ;  a  table  spoonful  of  which  was  given  thrice  a 
day.  He  continued  gradually  increasing  the  dose,  until  his  patient  had  taken 
giv  of  the  tincture  in  24  hours,  3J  of  the  tincture  being  added  to  §vj  of  water. 
It  was  generally  given,  until  considerable  pain,  and  a  puriform  discharge  from 
the  vagina  was  produced.  1  cannot  say,  that  in  the  few  trials  I  have  made  of  it 
in  this  complaint,  the  beneficial  effects  have  been  so  conspicuous. 


79 

tation.  After  the  tender  state  is  nearly  subdued,  and  the  discharge 
has  become  more  chronic,  the  cold  bath,  tonics,  and  mild  vegeta- 
ble astringent  injections,  are  proper. 

Purulent  discharge  implies  previous  inflammation,  and  the  pre- 
sent existence  either  of  abscess,  ulceration,  or  a  morbid^change  of 
a  secreting  surface.  The  two  first  states  are  ascertained  by  exami- 
nation. The  last  chiefly  by  the  smarting  in  making  water,  and 
other  symptoms  excited  by  the  action  of  a  virus.  To  this  species 
belongs  the  gonorrhoea,  which  is  to  be  cured  by  mild  laxatives,  and 
injections,  first  of  acetite  of  lead,  and  then  of  sulphate  of  zinc,  dis- 
solved in  water.  The  two  first  states  are  to  be  managed  according 
to  the  causes  which  give  rise  to  them. 

On  the  whole,  then,  our  practice  in  fluor  albus,  unaccompanied 
with  organic  affection,  consists  in  rectifying  the  constitution,  bring- 
ing it  as  far  as  possible  to  a  state  of  perfect  health,  employing  topi- 
cal applications  in  the  form  of  injections,  and  avoiding  the  farther 
operation  of  exciting  causes. 

§  22.  AFFECTIONS  OF  THE  BLADDER. 

The  bladder  is  subject  to  several  diseases.  The  first  I  shall 
mention  is  stone.  This  excites  very  considerable  pain  in  the  region 
of  the  bladder,  remarkably  increased  after  making  water.  There 
is  also  irritation  about  the  urethra,  with  a  frequent  desire  to  void 
the  urine  ;  but  it  does  not  always  flow  freely,  sometimes  stopping 
very  unexpectedly.  The  urine  deposits  a  sandy  sediment,  and  is 
often  mixed  with  mucus.  These  symptoms  lead  to  a  suspicion 
that  there  is  a  stone  in  the  bladder,  but  we  can  be  certain  only  by 
passing  a  sound.     By  means  of  the  warm  ha\h,(r)  opiates,  and  the 

(~rj  Our  author  has  omitted  to  mention  the  efficacy  of  magnesia  in  calculous 
complaints,  as  recommended  by  Messrs.  Brande  and  Hatchet.  The  result  of  the 
inquiries  of  these  ingenious  gentlemen,  on  this  very  interesting  subject  has  been 
communicated  to  the  scientific  world  in  a  paper  printed  in  the  Philosophical 
Transactions  for  the  year  1810,  entitled  "  Observations  on  the  Effects  of  Magne- 
sia, in  preventing  an  increased  formation  of  the  Uric  Acid,  by  William  T. 
Brande."  This  gentleman  (in  a  communication  to  Sir  John  Sinclair)  says,  that 
the  best  method  of  giving  the  magnesia,  is  in  plain  water,  or  milk,  to  be  taken 
in  the  morning  early,  and  at  mid-day.     If  the  stomach  is  weak,  and  this  produ- 


80 

medicines  improperly  called  lithontriptics,  much  relief  may  be  ob- 
tained, and  very  often  the  stone  may  be  passed,  for  the  urethra  is 
short  and  lax,  so  that  calculi  of  great  size  have  been  voided.  But 
when  these  means  fail,  an  operation  must  be  performed.  This  has 
been  done  during  pregnancy,*  but  is  only  allowable  in  cases  of 
great  necessity.  Sometimes  the  stone  makes  way,  by  ulceration, 
into  the  vagina.f  It  has  even  been  known  to  ulcerate  through  the 
abdominal  integuments.J 

In  many  cases  the  symptoms  of  stone  are  met  with,  although 
none  can  be  found  in  the  bladder.  This  is  most  frequently  the  case 
with  young  girls,  previous  to  the  establishment  of  the  catamenia, 
or  with  women  of  an  irritable  habit.  There  is  no  organic  disease, 
nor  have  I  ever  known  it,  in  such  people,  end  in  a  diseased  struc- 
ture of  the  bladder  or  kidneys;  indeed,  they  rarely  complain  of 
uneasiness  about  the  kidneys.  I  have  tried  many  remedies,  such 
as  soda,  uva  ursi,  narcotics,  antispasmodics,  tonics,  and  the  warm 
and  cold  bath,  but  cannot  promise  certain  relief  from  any  one  of 
these.^  In  process  of  time,  the  disease  subsides  and  disappears. 
The  use  of  a  bougie  may  be  of  service,  for  the  state  of  the  urethra 

ces  flatulency  or  uneasy  sensations,  some  common  bitters,  such  as  gentian,  may 
be  taken  with  it;  if  it  purges,  a  little  opium  may  be  added.  He  supposes  its 
beneficial  operation  depends,  on  preventing  the  formation  of  acid  in  the 
stomach. 

The  dose  of  magnesia,  he  observes,  must  always  depend  upon  the  circum- 
stances of  the  case  ; — generally,  five  grains  twice  or  thrice  a  day  to  children  ten 
years  of  age  ;  fifteen  or  twenty  grains  to  adults. 

Mr.  Brande  has  always  given  the  common  magnesia,  although  he  remarks, 
that,  the  calcined  may  be  occasionally  used  with  advantage.  For  fuller  inforina- 
tion  on  this  subject,  the  reader  is  referred  to  Brande's  paper,  above  quoted,  in 
the  Phil.  Trans,  and  to  a  letter  from  Sir  John  Sinclair,  vide  Eclectic  Repertory, 
Vol.  111.  p.  120. 

Dr.  Gilbert  Blane,  so  well  known  in  the  medical  world,  has  also  written  an  in- 
teresting paper  on  the  effects  of  large  doses  of  mild  vegetable  alkali,  or  potassa 
oarbonata  in  gravel,  and  the  beneficial  effects  of  opium  combined  with  it. 

*  Deschamps,  Traite  de  l'Oper.  de  la  Taille,  Tome  IV  p.  9. 

f  Hildanus,  cent.  I.  obs.  68  and  69. 

i  Vide  Case  by  Mr.  Caumond,  in  Kecueil  Period. 

§  In  a  case  of  this  kind,  described  by  Mr.  Patton  as  a  spasmodic  affection  of 
the  neck  of  the  bladder,  calomel  appeared  to  cure  the  complaint.  London  Med. 
Journal,  Vol.  X.  p.  560.    The  use  of  the  bougie  may  be  proper. 


81 

often  produces  pain,  not  only  in  its  course,  but  general  uneasiness 
in  the  neighbouring  parts,  and,  indeed,  is  the  most  frequent  cause 
of  sympathetic  pain,  or  sensibility  of  the  vagina  or  vulva. 

Spasm  of  the  orifice  of  the  bladder,  with  an  irritable  state  of  the 
urethra,  may  succeed  labour,  or  attend  female  diseases,  and  occa- 
sions great  pain  in  voiding  the  urine.  It  requires  anodynes,  tepid 
fomentations,  laxatives,  and  sometimes  the  gentle  introduction  of 
the  catheter. 

Induration,  orscirrhus  of  the  bladder,  produces  symptoms  some- 
what similar  to  calculus,  but  there  is  a  greater  quantity  of  morbid 
mucus  mixed  with  the  urine ;  and  blood  with  purulent  matter  is 
discharged,  when  ulceration  has  taken  place.  No  stone  can  be 
found,  but  the  bladder  is  felt  to  be  hard  and  thick.  Sometimes  it 
is  much  enlarged  with  such  appearances,  as  give  rise  to  an  opinion, 
that  the  uterus  is  the  part  principally  affected.*  The  scirrhus  and 
ulceration  may  extend  to  the  uterus  and  vagina.  In  this  disease 
we  must  avoid  all  stimulants,  and  put  the  patient  on  mild  diet ; 
avoid  every  thing  which  can  increase  the  quantity  of  salts  in  the 
urine  ;  keep  the  bowels  open,  with  an  emulsion  containing  oleum 
ricini ;  and  allay  irritation  by  means  of  the  tepid  bath  and  opiates. 
Mercury,  cicuta,  uva  ursi,  &,c.  with  applications  to  the  bladder  it- 
self, have  seldom  any  good  effect,  and  sometimes  do  harm. 

Chronic  inflammation  of  the  mucous  membrane  of  the  bladder, 
produces  frequent  desire  to  void  urine,  and  the  discharge  of  vis- 
cid mucus,  which  sometimes  has  a  puriform  appearance.  Cicuta 
and  balsam  of  copaiba  seem  to  be  the  best  remedies. 

Polypous  tumoursf  may  form  within  the  bladder,  producing  the 


*  Morgagni  relates  an  important  case,  where  there  was  a  hard  painful  tumour 
in  the  hypogastric  region,  accompanied  with  fluor  albus,  uterine  hemorrhage, 
and  stillicidium  of  urine.  After  death,  the  bladder  was  found  very  large  and 
scirrhous,  with  two  large  bodies  in  the  cervix,  preventing  the  urine  from  being 
retained.  The  uterus  was  diseased  only  in  consequence  of  its  vicinity  to  the  blad- 
der.    Epist.  XXXIX.  art.  31. 

f  Of  this  disease  [  have  never  seen  an  instance ;  but  Dr.  Baillie  mentions  a  case, 
in  which  the  greater  part  of  the  bladder  was  filled  with  a  pojypus.  Morbid  Annt 
p.  298. 

12 


82 

usual  symptoms  of  irritation  of  that  organ.     Most  dreadful  suffer- 
ings have  been  caused  by  worms  in  the  bladder. 

In  consequence  of  severe  labour,  or  the  pressure  of  instruments, 
the  neck  of  the  bladder  may  become  gangrenous,  and  a  perfora- 
tion take  place  by  sloughing.  The  woman  complains  of  soreness 
about  the  parts,  and  does  not  void  the  urine  freely.  In  five  or  six 
days  the  slough  comes  off,  and  then  the  urine  dribbles  away  by  the 
vagina.  In  all  cases  of  severe  labour,  and  indeed  in  every  case 
when  the  urine  does  not  pass  freely  and  at  proper  intervals,  and 
especially  if  there  be  tenderness  of  the  parts,  we  must  evacuate  the 
water,  in  order  to  prevent  distension  and  farther  irritation  of  the 
bladder  ;  and  the  parts  must,  if  there  be  a  tendency  to  slough  or  to 
ulcerate,  be  kept  very  clean,  and  be  regularly  dressed,  in  order  to 
prevent  improper  adhesions.  If  the  bladder  should  give  way,  we 
must  try,  by  keeping  in  attentively  an  elastic  catheter,*  to  make 
the  urine  flow  by  the  urethra,  and  then  perhaps  the  part  may  heal. 
This  is  materially  aided  by  introducing  a  sponge  into  the  vagina 
so  as  to  press  on  the  aperture.  It  would  appear  that  a  very  good 
method  of  doing  so,  is  to  fix  a  thin  piece  of  sponge  on  the  side  of 
an  elastic-gum  bottle,  which  is  to  be  placed  in  the  vagina,  so  that 
the  sponge  be  applied  to  the  aperture.  The  urine  is  thus  retained 
and  should  be  drawn  off  at  short  intervals.  The  aperture,  if  the 
treatment  have  been  begun  as  early  as  the  tenderness  of  the  parts 
permit,  may  thus  gradually  contract,  and  at  last  be  shut  altogether.f 
If  it  remain  small  and  callous,  it  may  be  touched  with  caustic.  In 
a  curious  case  I  met  with,  there  was  an  attempt  by  nature,  to  plug 
up  the  opening.J  Puzos  justly  remarks,  that  it  is  always  the  blad- 
der, and  not  the  urethra,  that  suffers. 

*  This  succeeded  in  a  very  bad  case  related  by  Sedilliot,  Recueil  Period.  Tome 
I.  p.  187. 

f  Vide  some  cases  in  Med.  Chir.  Trans.  Vol.  VI.  p.  583. 

±  The  patient  to  whom  I  allude  had,  1  understood,  four  years  before  her  death, 
been  delivered  with  the  forceps,  and  soon  afterwards  had  incontinence  of  urine. 
I  found  a  large  perforation  in  the  bladder,  exactly  resembling  the  fauces  without 
an  uvula.  The  uterus  was  a  little  enlarged  and  indurated ;  and  its  mouth,  which 
was  ulcerated  and  fungous,  lay  in  this  opening,  projecting  into  the  bladder,  and 
closing  up  the  communication  betwixt  the  bladder  and  vagina. 


83 

•  Sometimes,"after  a  severe  labour,  the  woman  is  troubled  with  in- 
continence of  urine,  although  the  bladder  be  entire.  This  state  is 
often  produced  directly  by  pressure  on  the  neck  of  the  bladder; 
sometimes  it  is  preceded  by  symptoms  of  inflammation  about  the 
pelvis,  and,  in  such  cases,  the  os  uteri  is  often  found  afterwards  to 
be  turned  a  little  out  of  its  proper  direction,  and  the  patient  com- 
plains much  of  irregular  pains,  about  the  hypogastrium  and  back. 
When  she  is  in  bed,  some  of  the  urine  collects  in  the  vagina,  and 
comes  from  it  when  she  rises ;  after  she  is  up,  it  comes  from  the 
urethra  alone,  which  distinguishes  this  from  the  complaint  last  des- 
cribed. Time  sometimes  cures  this  disease.  The  cold  bath  is 
useful,  unless  it  increase  the  pain  ;  and  in  that  case,  the  warm  bath 
should  be  employed.  It  may  be  proper  to  use  the  bougie  daily, 
and  also  tincture  of  cantharides,  and  pressure. 

The  bladder  may  descend,  in  labour,  before  the  uterus,  pro- 
ducing much  pain ;  or  it  may  prolapse  for  some  time  previous  to 
labour,  attended  with  pains  resembling  those  of  parturition,  and 
sometimes  with  convulsive  or  spasmodic  affections.*  When  the 
prolapsus  vesicae  takes  place  as  a  temporary  occurrence  during 
labour,  or  antecedent  to  parturition,  we  must  be  careful  not  to 
mistake  the  bladder  for  the  membranes,  for  thus  irreparable  mis- 
chief has  been  done  to  the  woman.  The  bladder,  when  protruded, 
is  felt  to  be  connected  with  the  pubis.  It  retires  when  the  pain 
goes  off.  If  the  patient  be  not  in  labour,  the  uneasiness  is  to  be 
mitigated  by  keeping  the  bladder  empty,  and  allaying  irritation 
with  opiates,  and  taking  a  little  blood,  if  feverish  or  restless.  If" 
labour  be  going  on,  the  bladder  must  likewise  be  kept  empty,  and 
may,  during  a  pain,  be  gently  supported,  by  pressing  on  it  with 
two  fingers  in  the  vagina,  by  which  the  bladder  is  preserved  from 
injury.  In  the  unimpregnated  state,  it  sometimes  descends  be- 
twixt the  vagina  and  pelvis,  so  as  to  form  a  tumour  within  the 
vagina,  or  at  the  vulva.  It  produces  a  procidentia  of  the  vagina, 
but  the  tumour  is  formed  at  the  anterior  part  of  the  vulva,  instead 

*  In  a  case  related  by  Sandifort,  the  suppression  of  urine  was  always  attended 
with  convulsive  cough.  Lib.  I.  cap.  5.  And  in  a  case  related  by  Dr.  J.  Hamil- 
ton, where  prolapsus  took  pluce  before  parturition,  the  muscles  of  the  body  wen* 
spasmodically  agitated.    Cases,  &c.  case  9. 


84 

of  the  back  part,  as  in  the  ordinary  procidentia.  There  is  some 
degree  of  bearing-down  pain  in  walking,  particularly  when  the 
bladder  is  full.  Some  patients  complain  of  pain  in  the  groin, 
others  at  the  navel,  and  some  suffer  little  or  no  inconvenience,  ex- 
cept pain  about  the  bladder  when  it  is  distended.  If  the  disease 
have  continued  long,  or  if  the  procidentia  of  the  anterior  part  of 
the  vagina  be  considerable,  the  os  uteri  is  directed  backward  :  and 
when  the  finger  is  introduced  into  the  vagina,  the  anterior  part  of 
that  canal  can  be  pushed  up  farther  than  usual  over  the  fore  part 
of  the  cervix  uteri,  which  then  appears  to  be  elongated,  and  per- 
haps in  some  cases  the  anterior  lip  is  actually  lengthened.  In  a 
case  dissected  by  my  brother,  the  bladder  was  found  to  form  a 
hernia  on  both  sides  of  the  pelvis,  hanging  like  a  fork  over  the 
urethra.  This  procidentia  is  called  a  hernia*  vesicalis,  and  is  often 
attended  with  suppression  of  urine.  If  this  be  inattentively  ex- 
amined, it  may  be  taken  for  prolapsus  uteri ;  but  it  will  be  found 
to  diminish,  or  even  disappear,  when  the  urine  is  voided  ;  and  by 
pressure  the  urine  may  be  forced  through  the  urethra. 

The  hernia,  or  procidentia  vesicalis,  is  to  be  remedied  by  the 
use  of  a  globe  pessary,  or  one  of  an  egg-shape ;  and  if  there  be 
much  relaxation  of  the  vagina  or  parts  of  the  outlet  of  the  pelvis, 
astringent  injections  and  an  elastic  support  acting  on  the  perineum 
will  be  useful.  Straining  and  all  muscular  exertion  should  be 
avoided.  Sometimes  it  is  combined  with  calculus  in  the  bladder. 
In  this  case,  it  has  been  proposed  to  open  the  bladder,  extract  the 
stone,  and  keep  up  a  free  discharge  of  urine  through  the  urethra, 
in  order  to  allow  the  communication  with  the  vagina  to  heal.  Des- 
champs  advises,  that  the  opening  should  be  made  near  the  pubis, 
and  not  at  the  posterior  part  of  the  tumour,  lest  that.part  of  the 
bladder  be  cut,  which  when  the  tumour  is  reduced,  would  com- 
municate with  the  abdominal  cavity.  I  can  see  no  necessity  for 
making  any  change  in  the  mode  of  extracting  the  stone  on  account 
of  the  procidentia. 

•  Vide  the  Memoirs  and  Essays  of  Verdier  and  Sabbatier,  and  Hoin.  Sandi- 
fort,  Diss.  Anat.  Path.  lib.  1.  cap.  iii. ;  and  Cooper  on  Hernia,  part  11.  p.  66. 


86 

$  23.  EXCRESCEJCCES  IN  THE  URETHRA. 

Excrescences  may,  notwithstanding  the  opinion  of  Morgagui. 
form  in  the  course,  or  about  the  orifice  of  the  urethra,*  and  gene- 
rally produce  great  pain,  especially  in  making  water  ;  on  which  ac- 
count, the  disease  has  sometimes  been  mistaken  for  a  calculous 
affection.  The  agony  is  at  times  so  great,  as  to  excite  convulsions, 
and  it  is  not  uncommon  for  the  patient  to  have  an  increase  of  her 
suffering  about  the  menstrual  period.  The  tumour  is  vascular, 
florid,  moveable,  and  exceedingly  tender.  When  excrescences 
grow  about  the  orifice  of  the  urethra,  they  are  readily  discovered; 
but  when  they  are  high  up,  it  is  much  more  difficult  to  ascertain 
their  existence.  Dr.  Baillief  says,  they  cannot  be  known,  but  by 
the  sensation  given  by  the  catheter  passing  over  a  soft  body. 
They,  however,  in  one  case,  were  discovered,  by  turning  the  in- 
strument to  one  side,  so  as  to  open  the  urethra  a  little.  J  When  their 
situation  will  permit,  it  is  best  to  extirpate  them  with  the  knife  or 
scissors;  or  if  near  the  orifice,  as  they  generally  are,  a  ligature  may 
be  applied.  Sometimes  they  have  yielded  to  the  bougie,  though 
they  had  returned  after  excision.^  The  removal  of  large  excrescen- 
ces, has  occasionally  been  attended  with  very  severe  symptoms.  || 

*  Mr.  Sharp  mentions  a  case  where  they  grew  in  small  quantity  upon  the  ori- 
fice, producing  excruciating  torment  till  they  were  extirpated.  Critical  Inq. 
p.  168. 

f  Morbid  Anatomy,  p.  321. 

i  In  the  instance  related  by  Mr.  "Warner,  the  urine  was  voided  in  drops  with 
great  pain,  especially  about  the  menstrual  period,  and  she  sometimes  even  had 
convulsions.  He  dilated  the  urethra,  by  inclining  the  catheter  to  one  «ide,  and 
thus  saw  two  excrescences  near  the  upper  end.  He  divided  or  laid  open  the 
urethra,  and  cut  oft"  the  excrescences  successfully  with  scissors.     Cases,  p.  309. 

§  Broomfield's  Surgery,  Vol.  II.  p.  296. 

S  In  the  patient  of  Mr.  Hughes,  the  disease  was  taken  at  first  for  prolapsus 
uteri,  for  there  was  a  substance  filling  the  os  externum,  and  appearing  without 
the  vulva.  It  was  a  spongy  excrescence,  from  the  whole  circumference  of  the 
meatus.  It  was  drawn  out  with  a  thread  passed  through  it,  and  then  cut  oft. 
Strangury,  with  pain  above  the  pubis,  and  fever,  took  place,  on  which  account 
the  catheter  was  introduced.  Suppression  of  urine  repeatedly  occurred ;  and 
as  it  was  often  difficult  to  introduce  the  catheter,  the  semicupium  was  employed, 
and  always  with  advantage  ;  but  once  after  it  she  became  faint,  and  the  limbs 


86 

The  daily  use  of  the  bougie,  for  some  time  after  extirpation,  is  of 
service.* 

Sometimes  the  urethra  is  partially,  or  totally  inverted,!  forming 
a  tumour  at  the  vulva,  attended  with  difficulty  and  pain  in  voiding 
urine.  A  slight  inversion  may  be  relieved  by  a  bougie ;  when  there 
is  a  considerable  prolapsus,  the  part  may  be  cut  off.  The  urethra 
is  sometimes  contracted  by  a  varicose  state  of  its  vessels,  or  by  a 
stricture;  but  these  are  not  common  occurrences.  In  continued 
irritation  of  the  urethra,  with  difficulty  of  voiding  water,  the  bougie 
is  often  of  great  service,  even  although  there  should  be  no  contrac- 
tion of  the  canal  itself.  Sometimes  the  urethra  is  preternaturally 
dilated,;}/ but  this  does  not  necessarily  cause  incontinence  of  urine. 

The  mucous  coat  of  the  urethra  is  sometimes  thickened,  and 
its  vessels  become  varicose.  This  produces  general  swelling  of 
the  urethra,  felt  by  the  finger  in  the  course  of  it,  pain  on  pressure, 
and  in  coitu,  with  a  discharge  of  mucus,  and  tormenting  desire  to 
make  water.  When  the  patient  bears  down,  the  urethra  is  partially 
inverted,  and  appears  swelled  and  vascular.  These  vessels  should 
be  scarified,  the  part  bathed  with  an  astringent  lotion,  and  gentle 
pressure  made  with  a  thick  bougie. 


were  convulsed.  A  stricture  being  suspected  at  the  upper  part  of  the  urethra,  a 
bougie  was  introduced,  and  kept  in  the  canal,  which  removed  the  symptoms. 
Med.  Facts  and  Obs.  Vol.  111.  p.  26. 

*  In  Mr.  Jenner's  case  the  irritation  of  the  bladder  was  great,  and  the  menses 
were  irregular.  A  fungus  was  found,  filling  the  orifice  of  the  urethra;  this  was 
cut  off,  and  the  bougie  used  for  an  hour  every  day  for  a  fortnight  ;  a  little  before 
the  extirpation,  a  hemorrhage  took  place  from  the  excrescences.  Vide  Lond. 
Med.  Journal,  Vol.  VII.  p.  160. 

j-  If.  Sernin  relates  a  case  of  a  girl,  eleven  years  of  age,  who  from  her  fifth 
year  had  been  subject  to  frequent  attacks  of  difficulty  in  voiding  the  urine.  He 
had  an  opportunity  of  examining  her  after  a  violent  attack,  and  found  a  cylindrical 
body,  4  inches  long,  projecting  from  the  vulva;  and  whenever  she  attempted  to 
make  water,  this  projection  swelled  up.  It  was  amputated  with  success.  Recueil 
Period.  Tom.  XVII.  p.  304. 

£  In  Dr.  Chamberlain's  patient,  who  had  the  hymen  imperforated,  the  urethra 
was  so  dilated  as  to  admit  the  finger ;  and  Portal  found  it,  in  an  analogous  case, 
dilated  so  as  to  form  a  cul-de-sac,  admitting  the  point  of  the  thumb.  Cours 
d'Anat.  Medicale,  Tom.  111.  p.  476. 


87 

§  24.  DEFICIENCY  AND  MALFORMATION  OF  THE  UTERUS. 

The  uterus  may  be  larger  than  usual,  or  uncommonly  small,* 
or  it  may  be  altogether  wanting.f  Unless  these  circumstances  be 
combined  with  some  deficiency,  or  unusual  conformation  of  the 
external  parts  or  vagina,  the  peculiar  organization  is  not  known 
till  after  death.  It  is,  however,  not  uncommon  for  the  external 
parts  to  be  very  small,  when  the  uterus  is  of  a  diminutive  size; 
and  when  it  is  altogether  wanting,  the  vagina  is  either  very  short, 
or  no  traces  of  it  can  be  found.  In  either  of  these  cases,  no  at- 
tempts should  be  made  to  discover  a  uterus  by  incisions,  unless, 
from  symptoms  of  accumulation  ,of  the  menses,  we  are  certain 
that  a  uterus  really  exists.J  In  some  instances,  the  skin  at  the 
point,  corresponding  to  the  situation  of  the  orifice  of  the  vagina, 
has  been  pressed  in,  so  as  to  form  a  short  sac,  which,  in  the  erect 
posture,  prolapsed  like  a  bag.  This  has  been  cut  in  search  of  the 
uterus,  and  nothing  found  but  cellular  substance.  It  has  been  sup- 
posed that  peculiar  feelings  about  the  monthly  period,  or  the  ex- 
istence of  sexual  desire,  indicated  the  presence  of  ovaria.     These 

*  Morgagni  mentions  a  porter's  wife,  in  whom  the  uterus  was  found  not  above 
an  inch  long,  and  without  any  ovaria.  The  pudendum  was  extremely  small,  and 
there  was  scarcely  any  appearance  of  a  clitoris.  In  the  Phil.  Trans,  for  1805, 
there  is  a  case  where  the  uterus  of  a  woman,  29  years  of  age,  was  not  larger 
than  in  the  foetal  state,  and  scarcely  any  appearance  of  ovaria.  She  ceased  to 
grow  at  ten  years  of  age,  had  no  hair  on  the  pubis,  never  menstruated,  and  had 
an  aversion  to  men.  1  have  seen  the  uterus  of  the  adult  not  larger  than  that  of 
a  child ;  the  woman  never  menstruated,  and  had  very  flat  breasts. 

f  Columbus  dissected  a  woman  who  always  complained  of  great  pain  in  coitu. 
The  vagina  was  very  short,  and  had  no  uterus  at  its  termination. 

Fromondus  relates  an  instance,  where  the  place  of  the  os  externum  was  occu- 
pied with  a  cartilaginous  substance. 

Morgagni  was  consulted  by  a  barren  woman,  whose  vagina  was  only  a  third 
part  of  the  usual  length,  and  its  termination  felt  firm  and  fleshy.  He  advised  a 
dissolution  of  the  marriage. 

M.  Meyer,  in  Schmucker's  Essays,  mentions  a  case  where  the  vagina  and 
uterus  were  wanting,  but  the  ovaria  existed.  The  labia  and  clitoris  were  small, 
and  there  was  no  nymphae.  Mr.  Ford  dissected  a  child  who  had  no  vagina, 
uterus,  or  ovaria.  The  urethra  and  rectum  terminated  close  to  each  other.  Med. 
Facts,  Vol.  V.  p.  92. 

i  Nabothus  mentions  a  rash  operator,  who  undertook,  by  incision,  to  find  the 
uterus  ;  but  after  cutting  a  little,  he  came  to  some  vessels  which  obliged  him  to 
stop. 


88 

have  sometimes  been  found  attached  to  a  mass  of  cellular  sub- 
stance, or  even  to  the  bladder. 

The  uterus  may  be  double  :*  in  this  case  there  is  sometimes  a 
double  vagina,  but  generally  only  one  ovarium  and  tube  to  each 
uterus.     This  conformation  does  not  prevent  impregnation. 

The  uterus  is  sometimes  divided  into  two,  by  a  septum  stretch- 
ing across  at  the  upper  part  of  the  cervix  ;f  or  the  os  uteri,  is  al- 
most, or  altogether  shut  up;J  by  a  continuation  of  the  lining  of  the 
womb  or  vagina,  or  by  adhesion,  consequent  to  ulceration,  or  by 
original  conformation  ;  and  in  this  last  case,  the  substance  of  the 
os  uteri  is  sometimes  almost  cartilaginous.  The  menses  either 
come  away  more  or  less  slowly,  according  to  the  size  of  the  aper- 
ture, or  are  entirely  retained  when  there  is  no  perforation.  As 
long  as  the  menses  are  discharged,  nothing  ought  to  be  done ;  but 
if  they  are  completely  retained,  and  violent  and  unavailing  efforts 
made  for  their  expulsion,  an  opening  must,  as  a  matter  of  neces- 
sity, be  made  from  the  vagina.  In  such  cases,  the  uterus  has  been 
tapped  with  success  ;^  but  it  has  also  happened,  that  fatal  inflam- 
mation has  succeeded  the  operation. 

The  vessels  are  sometimes  enlarged;  and  I  have  seen  the  sper- 
matic veins  extremely  varicose,  in  an  old  woman  who  had  been 
subject  to  piles;  but  I  do  not  know  that  any  particular  inconveni- 
ence results  from  the  veinous  enlargement. 

*  Vide  Hist,  de  l'Acad.  de  Sciences,  1705,  p.  47.— Haller  Opusc.  path.  60. 
Acrell's  cases.— Purcell  in  Phil.  Trans.  LXIV.  p.  474.— Canestrini  in  Med.  Facts, 
Vol.  III.  p.  171.— Valisneri  met  with  a  double  uterus  and  double  vulva.  Opera, 
Tom.  III.  p.  338.— Dr.  Pole  describes  a  double  uterus,  in  the  4th  Vol.  of  Mem. 
of  Medical  Society,  p.  92. 

■f  Baillie's  Morbid  Anatomy,  chap.  six. 

*  Littre  found  it  almost  closed,  by  a  continuation  of  the  inner  surface  of  the 
vagina,  Mem.  de  l'Acad.  de  Sciences,  1704,  p.  27;  and  in  the  seventh  month  of 
pregnancy,  closed  by  a  glandular  substance.  1705,  p.  2.— Morgagni  found  it  shut 
with  a  membrane.  Epist.  XLVI.  art.  17.— Boehmer  quite  shut  up.— Obs.  Anat. 
fasc.  2.  p.  62. — Ruysch  saw  it  so  small  as  scarcely  to  admit  a  pin  ;  and  Sandifort 
so  well  closed,  that  nothing  but  air  could  be  forced  through  it.  Obs.  Anat.  Path, 
lib.  II.  c.  ii.  p.  67. 

§  The  menses  being  retained,  and  great  pain  excited,  they  were  let  out  with 
u  trocar  by  Schutzer.     Vide  Sandifort,  p.  69. 


89 


§  25.  HYSTER1TIS. 

The  uterus  is  subject  to  inflammation ;  but  in  the  unimpreg- 
nated  state,  it  is  not  common  for  the  womb  to  be  the  original  seat 
of  acute  inflammation.  After  parturition,  it  is  very  frequently  in- 
flamed •  and  this  will  hereafter  be  considered.  Inflammation  is 
discovered  by  pain  in  the  hypogastric  region,  accompanied  with 
tenison,  and  the  part  is  tender  to  the  touch ;  there  is  acute  pain 
stretching  to  the  back  and  groins  ;  the  bladder  is  rendered  irritable ; 
and  acute  fever  accompanies  these  symptoms.  Blood-letting, 
purges,  fomentations,  and  blisters  are  to  be  used,  as  in  other  cases 
of  peritoneal  inflammation.  Wounds  of  the  uterus  are  dangerous, 
in  proportion  to  the  inflammation  they  excite.* 

Chronic  inflammation  of  the  cervix  uteri  is  not  uncommon.  The 
os  uteri  is  open,  soft,  and  tender  to  the  touch.  The  cervix  is  not 
materially  affected  in  size  or  hardness.  There  is  a  considerable 
discharge  of  white  mucus,  which  sometimes  becomes  puriform, 
and  this  is  often  mixed  with  blood ;  or  there  may  be  very  con- 
siderable uterine  hemorrhage.  The  patient  feels  pain  in  the  uterine 
region,  but  often  complains  more  of  pain  in  some  distant  part  of 
the  abdomen,  not  unfrequently  near  the  liver.  There  is  little 
fever,  but  the  patient  becomes  weak  from  discharge,  irritation,  and 
those  hysterical  affections  which  may  accompany  the  complaint. 
Examination  discovers  the  uterus  to  be  swelled,  and  it  is  painful 
when  pressed  with  the  finger. 

The  warm  sea-water  hip-bath,  gentle  saline  purgatives,  injection 
of  decoction  of  hemlock,  mild  diet,  and  the  use  of  cicuta  as  an 
anodyne,  are  proper  at  first.  Gardien,  I  find,  recommends  the 
use  of  emollient  injections,  conveyed  by  a  pipe,  connected  with  a 
receptacle  so  large  as  to  contain  as  much  fluid  as  will  permit  of  a 
continued  flow  for  eight  or  ten  minutes.  Of  this  I  have,  as  yet, 
no  experience.  Afterwards,  when  the  symptoms  are  so  far  sub- 
dued, the  use  of  the  cold  sea  bath,  bark  combined  with  bitters, 

*  In  one  instance  the  woman  was  murdered,  by  thrusting  a  piece  of  glass  up 
the  vagina  ;  and  Haller  notices  a  fatal  case,  in  which  a  piece  of  lead  was  thrust 
into  the  uterus. 

13 


90 

and  mild  injections  of  vegetable  astringents,  are  proper.  In  ob- 
stinate cases,  mercury  ought  to  be  tried,  with  a  view  of  altering 
the  action  of  the  parts ;  but  it  must  be  done  cautiously,  as  it  is 
hurtful  when  it  excites  without  rectifying  the  action. 

When  there  is  considerable  uterine  pain,  or  much  sensibility  of 
the  neighbouring  parts,  the  introduction,  at  night,  into  the  vagina, 
of  a  few  grains  of  extract  of  hemlock,  is  of  service.  Pain  about 
the  groin  is  relieved  by  leeches,  and  the  application  of  a  blister 
kept  open  by  savine  ointment. 

§  26.  ULCERATION  OF  THE  UTERUS. 

The  uterus  may,  from  irritation,  become  ulcerated  like  any 
other  part ;  purulent  matter  is  discharged,  the  patient  feels  pain 
in  coitu,  or  when  the  uterus  is  pressed,  and  sometimes  the  finger 
can  discover  the  ulcer.  Simple  ulceration  is  very  rare,  and  I  ap- 
prehend, will  always  heal,  by  keeping  the  parts  clean  with  mild 
injections.  Ulceration  from  morbid  poison  is  more  frequent.  Of 
this  kind  is  the  phagedena,  a  most  obstinate  and  dreadful  disease 
of  the  womb,  which  begins  about  its  mouth,  and  goes  on,  gradually 
destroying  its  substance,  until  almost  the  whole  of  it  be  removed  ; 
and  sometimes  it  spreads  to  the  neighbouring  parts.  This  disease 
is  marked  by  excruciating  pain  of  the  burning  kind,  in  the  region 
of  the  uterus ;  copious,  foetid,  purulent,  or  sanious  discharge,  al- 
ternating with  some  hemorrhage  ;  small  but  frequent  pulse,  wast- 
ing of  the  flesh,  and  occasionally  swelling  of  the  inguinal  glands  : 
no  tumour  is  felt  externally,  but  the  belly  is  flat.  Examination, 
per  vaginam,  discovers  the  destruction  which  has  taken  place,  and 
how  far  it  has  proceeded.  It  also  ascertains,  that  the  part  which 
remains  is  not  enlarged. 

On  inspecting  the  body  after  death,  the  pelvis  is  generally  found 
filled  with  intestines,  matted,  and  adhering  to  the  pelvis,  and  to 
one  another.  In  the  midst  of  the  mass,  there  are  sometimes  one 
or  two  simple  abscesses,  containing  healthy  pus.  On  tearing  out 
the  mass,  the  uterus  is  discovered  to  be  eat  away  all  to  the  fun- 
dus, or  a  small  part  of  the  body.  The  substance  is  very  little 
thickened,  but  resembles  soft  cartilage,  with  here  and  there  smaU 


91 

cysts,  not  larger  than  pin  heads.  The  ulcerated  surface  is  fork} 
flocculent,  and  has  a  dissolved  appearance,  whilst  the  substance  in 
its  immediate  vicinity  is  vascular  and  livid.  The  rapidity  of  the 
destruction  is  various  in  different  cases.  It  is  very  difficult  to  cure 
this  ulcer,  or  even  to  check  its  progress.  Sometimes  mercury  has 
effected  a  cure,  either  by  itself,  or  combined  with  cicuta ;  or  hyo- 
cyamus,  or  other  narcotics,  have  been  given  alone.  Nitrous  acid 
occasionally  gives  relief,  and  when  greatly  diluted  so  as  to  be 
weaker  than  vinegar,  forms  a  very  proper  injection.  A  very  weak 
solution  of  nitrate  of  silver,  is  also  a  good  topical  application.  Should 
the  pain  be  great,  tepid  decoction  of  poppies,  or  water  with  the 
addition  of  tincture  of  opium,  will  be  of  service  as  an  injection. 
Fomentations  to  the  lower  belly,  and  friction  with  camphorated 
spirits  on  the  back,  also  give  relief;  but  very  frequently  opium, 
taken  internally,  affords  the  only  mitigation  of  suffering,  and  the 
quantity  required  is  often  great. 

There  is  another  kind  of  ulcer,  which  attacks  the  cervix  and  os 
uteri.  It  is  hollow,  glossy,  and  smooth,  with  hard  margins;  and 
the  cervix,  a  little  beyond  it,  is  indurated,  and  somewhat  enlarged, 
but  the  rest  of  the  uterus  is  healthy.  The  discharge  is  serous,  or 
sometimes  purulent.  The  pain  is  pretty  constant,  but  not  acute ; 
and  the  progress  is  generally  slow,  though  it  ultimately  proves 
fatal,  by  hectic.  In  this,  and  all  other  diseases  of  the  uterus,  the 
morbid  irritation  generally  excites  leucorrhoea,  in  a  greater  or  less 
degree  ;  but  examination  ascertains  the  morbid  condition  of  the 
part.  Although  this  disease  be  very  different  in  its  nature  from 
the  former,  yet  the  mode  of  treatment  is  much  the  same.  Material 
benefit  may  be  derived  from  the  warm  salt-water  bath,  and  the 
regular  use  of  a  solution  of  some  saline  purgative,  or  a  laxative 
mineral  water,  such  as  that  of  Harrowgate  or  of  Cheltenham.  This 
is  especially  the  case,  when  the  ulcer  is  small,  or  when  the  part 
is  only  indurated,  ulceration  not  having  yet  taken  place.  In  this 
stage,  the  cervix  is  felt  hard  and  sensible  to  the  touch,  and  there  is 
leucorrhoea,  and  pain  in  the  uterine  region.  A  gentle  mercurial 
course  is  occasionally  of  service.  Some  may  consider  this  disease 
as  a  species  of  cancer,  but  the  ulcer  is  never  fungous 


92 

Excrescences  of  a  firm  structure,  and  broader  at  the  extremity 
than  at  the  attachment,  may  spring  from  the  os  uteri,  and  gene- 
rally, I  apprehend,  originate  from  a  lobulated  or  fissured  state  of 
the  parts.  They  bleed  readily  and  profusely  ;  but  when  not  irri- 
tated the  discharge  is  serous,  and  so  great,  that  thick  folds  of  cloth 
are  soon  wet  as  if  the  liquor  amnii  had  been  coming  away.  It  is 
evident  that  astringents  cannot  effect  a  cure,  as  they  do  not  alter 
the  nature  of  the  substance  which  secretes.  If  a  ligature  could  be 
passed  so  as  to  destroy  the  circulation  in  the  excrescence,  a  cure 
might  be  expected.  When  this  is  impossible,  we  can  only  palliate 
symptoms. 

A  peculiar  growth  is  described  by  the  late  Dr.  Clarke,*  under 
the  name  of  cauliflower  excrescence,  which  is  probably  of  the  na- 
ture of  that  I  speak  of.  It  springs  from  the  os  uteri,  the  base  is 
broad,  the  surface  granulated,  the  substance  brittle,  and  the  frag- 
ments broken  off  are  white.  Pressure  does  not  give  much  pain, 
but  the  patient  has  more  or  less  at  all  times ;  yet  not  of  the  lanci- 
nating kind.  The  discharge  is  at  first  like  fluor  albus,  and  stiffens 
the  linen,  though  frequently  it  becomes  watery  and  transparent. 
It  is  so  great,  that  when  the  excrescence  is  large,  it  wets  ten 
or  twelve  napkins  daily,  and  occasions  much  debility.  The  pro- 
gress is  variable,  and  sometimes  is  so  rapid,  that  the  pelvis  is  filled 
by  it  in  nine  months.  The  only  treatment  that  bids  fair  to  give 
relief,  is  the  application  of  the  ligature ;  but  the  peculiarity  is, 
that  when  the  vessels  are  constricted  by  this  during  life,  or  col- 
lapse after  death,  the  solidity  of  the  tumour  is  lost,  and  it  resem- 
bles merely  a  glairy  substance. 

Venereal  ulceration  may,  although  the  external  parts  be  sound, 
attack  the  uterus,  producing  a  sense  of  heat  with  pain.  There  is 
at  first,  very  little  discharge,  and  this  consists  of  mucus ;  but  if  the 
disease  be  allowed  to  continue,  foetid  purulent  matter  comes  away. 
The  ulcer  is  at  first  small,  and  there  is  no  hardness  about  the  os 
uteri,  nor  is  it  perceived  to  be  dilated ;  but  it  is  painful  to  the 
touch,  and  sometimes  bleeds  after  coition.  The  purulent  dis- 
charge appears  earlier  than  in  cancer,  but  the  health  for  a  time  is 

*  Vide  Trans,  of  a  Society,  &c.  Vol.  111.  p.  321. 


93 

not  affected.  Then  the  ulcer  spreads,  and  may  destroy  a  great 
part  of  the  womb  and  bladder,  and  occasion  fatal  hectic.  The 
history  of  the  patient  may  assist  the  diagnosis.  The  cure  consists 
in  a  course  of  mercury,  which  Hiave  always  found  produce  a  good 
effect  soon  after  the  commencement.* 

§  27.  SC1RRO-CANCER. 

Scirro-cancer  generally,  or  rather  I  may  say  always,  begins  in 
the  cervix  uteri.  It  may  take  place  in  the  prime  of  life,  but  is 
most  frequent  about  the  time  of  the  cessation  of  the  menses.  It 
begins  widi  leucorrhoeal  discharge,  succeeded,  after  a  longer  or 
shorter  time,  by  a  feeling  of  heaviness  or  heat,  and  darting  pains 
about  the  hypogastrium,  aching  in  the  back,  dull  pain  about  the 
upper  and  inner  part  of  the  thighs,  with  a  sense  of  bearing  down, 
together  with  dysuria  and  mucous  discharge  with  the  urine ;  glow- 
ing heat,  or  sometimes  stinging  pain  betwixt  the  pubis  and  sacrum, 
with  itchiness  of  the  vulva.  Menorrhagia  very  early  attends  the 
complaint,  and  sometimes  is  the  most  prominent  symptom  for  a 
considerable  time,  as  the  pain,  and  other  effects  of  the  disorder, 
may  be  late  of  appearing.  The  patient  is  often  troubled  with  flatu- 
lence, heartburn,  and  sometimes  with  vomiting,  and  cutaneous 
eruptions  from  sympathy  with  the  stomach.  The  general  health 
soon  suffers,  the  countenance  becomes  sallow,  the  pulse  quickens, 
the  strength  declines,  and  the  body  wastes.  Presently  a  foetid, 
purulent,  or  bloody  matter  is  discharged,  which  indicates  that  a 
cyst  has  burst,  and  the  disease  has  proceeded  to  ulceration.  Re- 
peated hemorrhages  are  now  apt  to  take  place,  and  hectic  is  es- 
tablished. The  pain  is  constant,  but  subject  to  frequent  aggrava- 
tions, and  the  weakness  rapidly  increases.  At  length  the  pain,  fe- 
ver, want  of  rest,  discharge,  and  loss  of  blood,  completely  exhaust 
the  patient ;  and  death  terminates  at  once  both  her  hopes  and  suf- 
ferings. 

As  first,  by  examination  per  vaginam,  the  uterus  is  felt  as  if  it 
were  enlarged ;  the  cervix  is  apparently  expanded,  and  the  os 
uteri  hard,  open,  irregular,  and  more  sensible  to  the  touch,  a  cir- 

*  Vide  Med.  Comment,  Yol.XJX.  p.  257.— Pearson  on  Cancer,  p.  119'. 


94 

cumstance  which  causes  pain  in  coitu.  A  little  blood  is  often  ob- 
served on  the  ringer  after  an  examination.  In  some  time  after  this, 
the  06  uteri  is  turgid,  with  many  irregular  projections  like  piles,  as 
if  it  contained  small  cysts,  and  presently  it  is  felt  to  be  ulcerated 
and  fungous;  but  sometimes  the  fungi  are  less  perceptible,  deep 
excavations  being  formed,  the  sides  of  which,  however,  after  death, 
are  found  to  be  fungous. 

The  cervix  uteri  is  sometimes  totally  indurated,  and  considerably 
enlarged,  before  ulceration  takes  place,  or  has  imbedded  in  it  a 
small  tumour;  but,  in  other  cases,  the  augmentation  is  much 
greater  after  ulceration,  than  before  it.*  If  the  disease  originally 
formed  a  distinct  tumour  in  the  cervix,  that  tumour  may  become 
as  large  as  the  fist,  adhering  to  the  pelvis  so  that  it  cannot  be  moved, 
and  pressing  so  much  on  the  rectum  or  bladder,  according  to  its 
situation,  as  to  give  rise  to  much  obstruction  in  the  evacuations 
from  either  of  these  parts.  The  uterus  itself  is  seldom  much  en- 
larged in  genuine  cancer ;  but  it  is  possible  whilst  the  cervix  is  af- 
fected with  this  disease,  that  the  body  of  the  uterus  may  have  un- 
dergone a  different  morbid  change.  The  tubes  and  ovaria  have 
been  said  to  participate  in  the  disease.f 

In  some  patients  the  disease  proves  fatal  very  early,  if  there 
be  profuse  hemorrhage  ;  in  others  great  devastation  takes  place, 
and  the  bladderj  or  rectum^  are  opened.     In  most  cases,  the  va- 

*  Vide  Stalpart  Vander  Wiel,  obs.  87. — Segerus  in  Mis.  Cur.  1671,  obs.  121. 
Notwithstanding  these  cancerous  excrescences  about  the  os  uteri,  a  woman  may 
conceive.  Dr.  Denman  relates  a  case  where  there  was  a  large  excrescence  in 
the  gravid  state,  with  profuse  bleeding.  The  head  of  the  child  was  lessened, 
but  the  woman  died  undelivered.  Vol.  II.  p.  65.  When  the  os  uteri  has  been 
affected  with  scirrhous,  and  the  woman  has  conceived,  the  uterus  has  sometimes 
been  ruptured,  or  the  woman  died  undelivered.  Hildanus,  cent.  I.  obs.  67. 
Horstius  Opera,  Tom.  II.  lib.  2.  obs.  5.  Blancard  Anat.  p.  233.  Hist,  de  l'Acad. 
des  Sciences,  1705,  p.  52. 

|  Vide  Prochaska  Annot.  Acad.  fasc.  2d. 

i  Le  Dran  attended  a  patient  who  had  all  the  symptoms  of  scirrhous  uterus, 
and,  by  examination,  fungous  excrescences  were  found  shooting  down  into  the 
vagina.  The  pain  was  continual,  and  could  only  be  mitigated  by  the  constant 
use  of  opium.  Urine  was  discharged  by  the  vagina,  and  after  death  the  bladder 
•was  found  to  be  perforated.  The  fundus  and  body  of  the  uterus  were  not 
much  diseased. 

§  M.  Tenon  found,  in  a  case  of  cancerous  uterus,  all  the  posterior  part  of  thg 


95 

gina  becomes  hard  and  thickened,  or  irregularly  contracted  with 
swelled  glands,  in  its  course. 

On  examining  the  diseased  part  after  death,  it  is  found  to  be 
thickened  and  indurated,  and  sometimes  its  cavity  is  enlarged. 
The  substance  is  of  a  whitish  or  brownish  colour,  intersected  with 
firm  membranous  divisions ;  and  betwixt  these  are  numerous 
small  cysts,  the  coats  of  which  are  thick  and  white.  They  contain 
a  vascular  substance,  which,  when  wiped  clean,  assumes  a  light 
olive  colour.  In  proportion  as  the  disease  advances,  some  of  the 
cysts- enlarge  and  thicken  still  more;  and,  when  opened,  are  found 
to  contain  a  bloody  lymph,  and  to  have  the  inner  surface  covered 
with  a  spongy  vascular  substance,  similar  to  that  which  fills  the 
small  cysts,  but  rather  more  resembling  fungus.  Presently  some 
of  these  cysts  augment  so  much  as  to  resemble  abscesses,  though 
they  are  not,  properly  speaking,  abscesses,  and  soon  afterwards  they 
burst. 

It  is  extremely  rare  for  a  cyst  to  burst,  or  fungi  to  shoot  out  on 
the  exterior  surface  of  the  uterus,  which  is  covered  with  the  peri- 
toneum. The  position  of  the  uterus  is  often  natural,  but  some- 
times it  is  inclined  to  one  or  other  side,  or  approaches  to  a  state  of 
retroversion. 

As  this  disease  is  apt  to  be  mistaken  for  fluor  albus,  menorrhagia, 
nephritis,  or  dyspepsia,  it  is  of  great  importance  that  the  practi- 
tioner should  be  on  his  guard,  and  examine  early  and  carefully  per 
vaginam.  Much  harm  is  done  by  the  use  of  extringent  injections 
meant  to  cure  the  supposed  fluor  albus. 

This  is  a  very  hopeless  disease,  but  still  much  may  be  done  to 
check  its  progress,  or  mitigate  its  symptoms.  When  uneasy  sen- 
sations, about  the  cessation  of  the  menses,  indicate  a  tendency  to 
uterine  disease,  we  find  advantage  from  the  insertion  of  an  issue 
in  the  arm  or  leg,  the  use  of  laxative  waters,*  and  spare  diet,f  and 

womb  ulcerated,  the  rectum  diseased,  and  a  communication  formed  betwixt 
them. 

*  Roederer  relates  a  case  where  scirrhous  swelling  was  cured  by  keeping  the 
bowels  open,  and  giving  every  third  evening,  from  ten  to  twenty  grains  of  calo- 
mel.—Haller  Disp.  Med.  Tomus  IV.  p.  670. 

f  Absolute  abstinence  has  been  recommended  by  Pouteau,  (Euvres  Post.  Tom. 
I.  p.  105.    He  relates  a  case,  which  was  cured  by  confining  the  patient  to  eau  de 


96 

flannel  dress.  If  by  examination  we  discover  any  alteration  in  the 
shape,  size,  or  sensibility  of  the  womb,  we  must  have  recourse  to 
the  daily  use  of  from  two  to  three  drachms  of  sulphas  potassse  cum 
sulphure ;  and  if  this  lose  its  effect,  some  other  laxative  must  be 
added.  The  tepid  sea  water  bath  every  night  is  likewise  of  great 
service.  When  there  is  much  sense  of  throbbing,  heat,  or  pain 
about  the  pelvis,  taking  blood  from  the  loins  by  cupping  is  of  ser- 
vice, and  the  patient  should  keep  in  a  horizontal  posture  as  much 
as  possible.  When  the  disease  has  evidently  taken  place,  we  must 
still  persevere  in  the  same  plan,  and  avoid  such  causes  as  excite 
action  in  general;  for  the  longer  we  can  keep  a  scirrhus  from  going 
into  a  state  of  activity  and  inflammation,  the  longer  do  we  keep  the 
disease  at  bay.  It  is  therefore  scarcely  necessary  to  add,  that  if 
the  patient  be  married,  she  must  not  sleep  with  her  husband.  We 
keep  the  parts  clean  by  injecting  tepid  water,  or  decoction  of  ca- 
momile with  hemlock  or  opium ;  allay  pain  by  anodynes ;  attend 
to  the  state  of  the  bowels ;  and  correct  stomachic  affections  by 
bitters,  and  other  suitable  remedies.  Mercury,  antimony,  iron, 
gold,  arsenic,  sarsaparilla,  aconitum,  cicuta,  &c.  have  been  given 
internally,  but  have  seldom  a  good  effect.  Indeed,  no  medi- 
cine can  be  depended  on  for  even  suspending  the  progress  of  the 
disease,  but  many  may  do  harm.  The  most  rational  practice  is, 
to  adopt  such  a  mild  system  as  shall  keep  down  action,  and  pre- 
vent the  parts  from  passing  on  to  ulceration.  Whilst  every  stimu- 
lus is  shunned,  we  may,  in  the  more  vigorous  constitution,  find  it 
useful  to  enjoin  considerable  abstinence  in  diet,  and  even  all  such 
mild  articles  of  food  or  beverage  as  ferment  in  the  stomach,  as  this 
state  of  the  aliment  aggravates  the  symptoms.  On  the  other  hand, 
if  we  find  that  the  abstemious  plan,  in  any  case,  by  weakening  too 
much,  permits  the  morbid  action  to  make  progress,  we  must  change 
the  regimen.  When  ulceration  has  taken  place,  much  may  still  be 
done  by  attention  to  the  use  of  the  syringe,  and  the  removal  of 
acrid  matter.  It  has  been  said,  that  very  weak  phosphoric  acid, 
injected  to  the  uterus,  allays  pain  more  effectually  than  anodynes, 

^glace. — Mr.  Pearson,  p.  113.  gives  two  successful  cases.  In  the  first,  the  uterus 
was  enlarged  and  retroverted,  but  by  very  spare  diet,  was  restored  to  its  natural 
state. 


97 

but  this  I  am  unable  to  confirm  by  experience.  It  has  been  pro- 
posed to  produce,  with  an  extracting  instrument,  a  prolapsus  uteri, 
and  then  cut  off  the  protruded  womb.  Several  years  ago,  Dr. 
Osiander  of  Gotlingen,  published  an  account  of  his  mode  of  extir- 
pating the  cancerous  neck  of  the  womb,  by  transfixing  it  with  liga- 
tures, and  thereby  pulling  it  so  low,  and  keeping  it  so  steady,  as  to 
enable  him,  with  a  history,  to  cut  off  the  diseased  part.  The 
bleeding  is  restrained  by  astringents.  At  the  time  of  publication, 
he  says  he  had  performed  the  operation  nine  times,  with  success. 
Dupuytren  has  also  performed  the  operation.  In  one  instance,  he 
required  to  remove,  at  two  different  times,  the  diseased  substance, 
as  it  still  returned.  Recamier  tried  the  effect  of  caustic  conveyed 
by  a  speculum,  but  the  result  has  not  yet  been  published.*  This 
operation  has  not  yet  been  performed  in  this  country,  but  this 
much  may  be  said  in  favour  of  it,  that  genuine  cancer  is,  if  left  to 
itself,  always  a  mortal  disease.-}- 


§  28.  TUBERCLES. 

Tubercles  are  common  in  the  uterus,  insomuch  that  M.  Bayle 
says,  that  in  seven  months  he  met  with  fourteen  cases.  They  con- 
sist at  first  of  fleshy  matter,  but  in  process  of  time  become  more 
like  cartilage,  or  even  bony,  especially  on  their  surface.^  On  ex- 
amining the  tumour,  it  is  sometimes  found  to  be  intersected  with 
membranous  divisions ;  and  a  section  always  exhibits  a  pretty 
compact  granulated  surface  without  vessels.  A  tubercle  may  take 
place  in  one  spot,  and  all  the  rest  of  the  uterus  may  be  healthy, 
and  nearly  of  the  natural  size.  The  magnitude  of  the  tubercle  is 
very  variable,  and  it  may  either  project  on  the  outer  surface,^  or 

*  Vide  Diet,  des  Sciences  Medicales,  art.  Matrice  et  Hysterotomie. 

f  Vide  Edin.  Journal  for  July,  1816. 

t  Sandifort  Obs.  Anat.  Path.  lib.  1.  cap.  viii. — Bayle  in  Jour,  de  Med.  Tome  V. 
p.  62. — Murray  de  Osteosteamate,  p.  14.  et.  seq.     Gardien,  T.  1.  p.  421. 

§  Professor  Francis  gives  the  history  of  an  enormous  fleshy  tubercle,  proceed- 
ing by  a  small  pedicle  from  the  fundus  of  the  uterus,  which,  together  with  the 
excrescences  connected  with  it.  weighed  rather  more  than  100  pounds     TEA, 

1-1 


98 

within  the  cavity  of  the  womb ;  and  in  this  last  case,  the  adhesion 
to  the  surface  of  the  cavity  is  generally  slight*  after  the  tubercle 
has  fully  projected.  In  this  it  differs,  even  in  its  most  detached 
state,  from  polypus,  which  is  attached  not  by  cellular  substance, 
but  by  a  pedicle.  One  or  more  of  these  may  be  thrown  off,  with 
pains  like  those  of  labour.  Sometimes  there  are  a  great  many  tu- 
bercles, which  are  found  in  various  stages  of  projection,  and  the 
uterus  may  become  greatly  enlarged,  and  very  irregular  exter- 
nally.f 

In  one  case  the  size  of  the  womb  was  large,  and  two  thick  hard 
ridges  could  be  felt  in  the  abdomen,  extending  obliquely  up  by  the 
sides  of  the  umbilicus.  The  lower  and  anterior  part  of  the  womb 
Mas  large,  and  filled  the  brim  of  the  pelvis  like  a  child's  head; 
whilst  near  the  promontory  of  the  sacrum,  the  os  uteri  was  felt 
healthy,  though  compressed.  This  woman  had  no  complaint  ex- 
cept what  proceeded  from  bulk  ;  the  bladder,  contrary  to  expecta- 
tion, was  not  in  any  degree  affected ;  the  stools  easy,  and  menstru- 
ation regular. 

I  have  never  seen  the  tubercle  end  in  ulceration,  nor  the  sub- 
stance of  the  uterus,  although  thickened,  have  abscess  formed  in 
it.  This  observation  I  find  confirmed  by  other  practical  writers, 
who  state  that  it  tends  not  to  suppuration,  but  ossification.  The  ef- 
fects of  this  disease  are  chiefly  mechanical,  and  often  altogether 
trifling ;  at  other  times,  we  have  a  pain  in  the  back,  and  some- 
times in  the  hypogastrium,  which,  if  there  be  much  enlargement 
of  the  womb,  is  swelled,  hard,  and  irregular,  dyspeptic  symptoms, 
leucorrhcea,  and  at  length  feverishness,  and  gradual  loss  of  strength. 
The  progress  is  generally  slow,  unless  the  cervix  uteri,  which  is 
always  souhd  with  regard  to  this  disease,  be  affected  with  phage- 
dena or  cancer,  or  unless  simple  inflammation  be  excited  by  pres- 
sure on  some  neighbouring  part.  That  is  to  say,  this  disease,  oc- 
curring by  itself,  is  not  dangerous  or  hurtful,  except  by  mechani- 
cal or  sympathetic  irritation.    During  the  active  stage,  pain  is  per- 


*  KaiUie's  Morbid  Anatomy,  chap.  six. 

•j-  1  hare  found  the  uterus  as  large  as  a  child's  head  of  a  year  old,  with  many 
projections  and  tubercles. — Peyer  has  a  similar  case,  Parcrg1.  Anat.  p.  131. 


•      99 

haps  felt,  but  it  ceases  when  the  tumour  ceases  to  grow,  which  it 
often  does.  I  have  slated  that  the  cervix  is  not  attacked  by  this 
disease ;  but  it  may  commence  in  the  lower  part  of  the  body  of 
the  uterus,  and  extend  downwards  as  well  as  outwards,  so  as  to 
appear  to  have  begun  in  the  cervix.  Menstruation  may  be  ren- 
dered irreeulaf,  but  sometimes  continues  unaffected. 

This  disease  can  only  be  confounded  with  diseased  ovarium,  but 
it  is  harder  when  felt  through  the  belly,  not  so  moveable  at  first, 
and  a  difference  may  generally  be  felt  per  vaginam.  It  may  be 
combined  with  tumour  of  the  ovarium.  On  introducing  the  finger 
into  the  vagina  in  the  early  stage,  the  uterus  is  felt  enlarged,  and 
bulging  either  before  or  behind ;  and  the  lump  is  a  little  painful 
wThen  pressed.  It  is  felt  to  make  a  part  of  the  womb,  and  very 
often  is  situated  on  the  anterior  surface,  in  contact  with  the  blad- 
der.    The  cervix  may  be  a  little  developed,  but  is  healthy. 

No  remedy  has  any  power  in  removing  the  diseased  substance, 
and  therefore  our  treatment  consists  in  palliating  symptoms,  espe- 
cially in  attending  to  the  bladder  and  bowels.  We  also  upon  gene- 
ral principles  keep  down  activity,  and  guard  against  inflammatory 
action.  The  antiphlogistic  regimen  should  be  pursued  in  modera- 
tion. The  bowels  especially  should  be  kept  open,  and  every 
source  of  irritation  removed.  The  tepid  bath  is  useful.  Women 
may  live  a  long  time,  even  although  these  tumours  acquire  consi- 
derable magnitude. 

Sometimes  the  whole  uterus  is  a  little  enlarged,  and  changed  into 
a  white  cartilaginous  substance,  with  a  hard  irregular  surface ;  or 
it  may  be  enlarged  and  ossified,*  and  these  ossifications  may  take 
place    even  during  pregnancy .f     Steatomatous  or  atheromatous 


*  Vide  Mem.  de  l'Acad.  de  Chirurg.  Lieutaud  relates  a  case  of  a  woman  who 
had  a  tumid  belly,  and  complained  of  great  pain.  The  womb  was  not  much  larger 
than  usual,  but  it  was  almost  bony.  Hist.  Anat.  Med.  p.  320. — Grandchamp  found 
an  osseous  tumour,  as  large  as  the  fist,  inclosed  in  a  sac,  betwixt  the  uterus  and 
bladder.  It  produced  constant  ischuria,  relieved  only  by  lying  on  the  back.  Med. 
and  Phys.  Journal,  Vol.  III.  p.  587. 

j  Vide  Observ.  on  Abortion,  2d  edition,  p.  37. 


100 

tumours  of  various  sizes*,  or  sarcomatous!  or  scirrhus-likej  bodies, 
may  be  attached  to  the  uterus.  All  these  diseases  sometimes  at 
first  give  little  trouble.  Even  their  advanced  stage  has  no  pathog- 
nomonic mark,  by  which  they  can  be  discovered,  as  they  produce 
the  usual  effects  of  uterine  irritation.  I  must  also  add,  that  they 
are  very  little  under  the  power  of  medicine.  The  most  we  can  do, 
is  to  palliate  symptoms  ;  by  which,  however,  we  greatly  meliorate 
the  condition  of  the  patient. 

§  29.  SPONGOID  TUMOUR. 

The  uterus  is  more  frequently  affected  with  spongoid  tumour 
than  is  supposed;  many  cases  of  that  disease  passing  for  cancer. 
This  is  a  firm,  but  soft  and  elastic  tumour,  the  substance  of  which 
bears  some  resemblance  to  brain,  and  contains  cysts  of  different 
sizes,  filled  with  red  serum  or  blood,  or  bloody  fungus,  according 
to  circumstances.  There  is  no  certain  way  of  distinguishing  or 
discovering  this  disease  in  its  early  stage,  for  it  often  gives  very 
little  trouble,  and  any  symptoms  which  do  occur,  are  common  to 
other  diseases  of  the  womb.  The  tumour,  however,  enlarges,  and 
can  at  length  be  felt  through  the  abdominal  parietes.  It  is  soft  and. 
elastic,  and  on  the  first  application  of  the  hand,  feels  very  like  a 
tense  ventral  hernia.  There  may  be  two  or  more  tumours  of  un- 
equal sizes  in  different  parts  of  the  belly,  which  can  be  felt  to  have 
a  connexion  with  each  other,  and  may  frequently  be  traced  to  the 
pubis.  Per  raginam,  the  state  varies  in  different  cases;  but  by 
pressing  on  the  external  tumour  at  the  same  time,  we  discover  its 
connection  with  the  womb  below.  We  may  find  ulceration,  or 
the  os  uteri  soft,  and  tumified,  and  opened,  or  the  posterior  lip  may 
be  lost  in  a  soft  elastic  tumour,  and  quite  obliterated,  whilst  the 


*  Vide  Rhodius,  cent.  III.  ob.  46.— Bcehmer  Obs.  Anat.  fasc.  2d.— Stoll  Ratio 
Med.  part  II.  p.  379. 

■\  Vide  Friedus,  in  Sandifort's  Observ.  lib.  I.  c  viii.  and  a  case  by  Sandifort 
himself,  where  the  tumour  adhered  by  a  cord,  lib.  IV.  p.  113. 

}  Baader  Obs.  Med.  ob.  29.  p.  170. 


101 

anterior  one,  after  a  pretty  careful  examination,  is  felt  high  up,  and 
apparently  sound.  Pressure  seldom  gives  pain,  till  ulceration  is 
about  to  take  place,  and  no  blood  is  usually  observed  on  the  fin- 
ger after  examination,  unless  a  fungous  has  protruded.  So  far  as 
I  have  seen,  fluor  albus  is  a  rare  attendant  on  this  disease  in  the 
early  stage,  and  litde  inconvenience  is  at  that  period  produced,  ex- 
cept what  may  sometimes  result  from  pressure  on  the  bladder, 
causing  strangury  or  suppression  of  urine,  attended  with  fits  of 
considerable  pain,  like  those  excited  by  a  stone.  Slight  dischar- 
ges of  blood  generally  attend  the  formation  of  the  disease  ;  and  at 
this  early  stage,  the  os  uteri,  and  sometimes  die  cervix,  may  be 
felt  tumid,  smooth,  and  elastic.  The  complexion  is  sallow,  but 
the  health  is  tolerably  good,  till  ulceration  or  inflammation  take 
place.  Ulceration  may  happen  in  different  parts;  it  may  be  di- 
rected to  the  vagina,  and  then  we  have  foetid  bloody  discharge,  or 
sometimes  considerable  hemorrhage,  and  ultimately  the  bladder  or 
rectum  is  involved  in  the  destruction  :  or  bloody  fungus  may  pro- 
trude from  the  exterior  surface  of  the  uterus  into  the  general  cavi- 
ty of  the  abdomen,  and  at  length  the  bowels  become  inflamed  and 
glued  together:  or  the  tumour  may  adhere  to  the  parietes  of  the 
abdomen,  and  the  skin  after  becoming  livid  gives  way,  and  a  fun- 
gus shoots  out  from  the  belly.  As  the  disease  advances  towards 
ulceration,  the  health  is  more  impaired,  hectic  fever  takes  place, 
and  the  patient  is  ultimately  cut  off. 

The  whole  treatment,  I  am  sorry  to  say,  consists  in  palliating 
such  sympathetic  or  local  symptoms  as  may  arise  in  the  course  of 
the  disease. 

[§  30.  CAULIFLOWER  EXCRESCENCE  FROM  THE  OS  UTERI. 

Dr.  John  Clarke  of  London  considers  himself  as  the  first  writer 
who  has  taken  notice  of  this  disease. 

The  cauliflower  excrescence,  according  to  him,  arises  always 
from  some  part  of  the  os  uteri.  As  several  of  the  early  symptoms 
are  not  very  distressing  to  the  patient,  the  tumour  in  the  beginning 
is  rarely  the  subject  of  medical  attention.  The  first  changes  of 
structure  have  therefore  not  been  observed.  In  general  the  tumour 


102 

is  not  less  than  the  size  of  a  blackbird's  egg.  At  this  period  it 
makes  an  irregular  projection,  and  has  a  base  as  broad  as  any  other 
part  of  it,  attached  to  some  part  of  the  os  uteri.  The  surface  has 
u  granulated  feel,  considerable  pressure  on  handling  it,  does  not 
occasion  any  sense  of  pain.  The  remainder  of  the  os  uteri,  will  at 
this  period,  be  found  to  have  no  sensible  alteration  of  structure. 
By  degrees  more  and  more  of  the  circle  of  the  os  uteri,  and  the 
external  part  of  the  cervix  uteri,  become  affected  with  the  same 
morbid  alteration  of  structure,  till  at  length  the  whole  is  involved 
in  the  disease. 

The  growth  is  in  some  cases  slow,  but  in  others  rapid,  so  that 
in  the  course  of  nine  months,  it  will  sometimes  entirely  fill  up  the 
cavity  of  the  pelvis,  and  block  up  die  entrance  of  the  vagina. 

As  the  bulk  of  the  tumour  increases,  the  granulated  structure 
becomes  more  evident,  and  is  found  to  resemble  very  much  the 
structure  of  the  cauliflower  when  it  begins  to  run  to  seed.  In  most 
cases  it  is  of  a  brittle  consistence,  so  that  small  parts  of  it  will  come 
away,  if  it  be  touched  too  rudely ;  and  such  pieces  appear  to  be 
very  white.  Sometimes,  though  no  violence  has  been  used,  small 
portions  of  a  white  substance  come  away  with  the  urine  of  the 
patient,  and  in  the  discharge  from  the  vagina. 

When  the  tumour  has  arrived  at  a  size  greater  than  that  of  the 
os  uteri,  it  spreads  very  much,  and  as  the  base  is  the  smallest  part 
of  the  tumour,  persons  not  conversant  with  the  disease,  have  often 
mistaken  it  for  polypus.  A  little  attention,  however,  to  the  feel  of 
the  tumour,  and  the  breadth  of  its  base,  will  be  sufficient  to  distin- 
guish them. 

In  the  very  early  state  of  the  cauliflower  excrescence,  a  dis- 
charge from  the  vagina  takes  place  like  fluor  albus ;  it  very  soon 
becomes  thin  and  watery,  and  is  sometimes  tinged  with  blood.  In 
most  cases  upon  coming  away,  it  is  apparently  as  thin  and  trans- 
parent as  pure  water ;  but  the  linen  on  which  it  is  received,  when 
dry  becomes  stiff,  as  if  it  had  been  starched.  The  quantity  of  the 
discharge  when  the  excrescence  is  large,  will  sometimes  be  suffi- 
cient to  wet  thoroughly  ten  or  twelve  napkins  in  a  day.  Now  and 
then  a  discharge  of  pure  blood  appears.  When  this  ceases,  the  dis- 


103 

charge  of  thin  transparent  fluid  re-appears.  An  offensive  odour 
generally  accompanies  the  discharge,  which  is  greatest  when  there 
has  lately  been  an  evacuation  of  pure  Mood,  or  of  the  catamenia. 
Mucus  has  sometimes  been  found  in  the  fluid  discharged,  but  puss 
never. 

Patients  labouring  under  this  disorder,  are  variously  affected 
with  regard  to  pain.  In  the  commencement  none  is  felt ;  but  dur- 
ing its  progress  pain  is  in  some  cases  experienced.  Generally  in 
the  advanced  stage,  the  patient  feels  pain  in  the  back,  and  in  the 
direction  of  the  round  ligaments  of  the  uterus.  The  pain  is  not  de- 
scribed to  be  lancinating,  as  in  cancer,  and  is  without  any  sensible 
aggravation  by  paroxysms;  but  on  the  whole,  it  is  most  felt  after 
the  patient  has  been  in  a  perpendicular  attitude. 

The  disease  attacks  indiscriminately  women  of  all  ages.  The 
patient  is  destroyed  by  the  debility  occasioned  by  the  profuse  dis- 
charge ;  and  in  the  course  of  the  disease,  she  always  becomes  ex- 
tremely emaciated  from  the  above  cause.  It  always  terminates 
fatally.  Respecting  the  treatment  of  this  disease,  nothing  satisfac- 
tory can  be  offered.  All  stimulating  substances  either  in  diet  or  me- 
dicine, seem  to  aggravate  it,  by  increasing  the  discharge;  and  no  as- 
tringents internally  given  appear  to  lessen  it.  The  only  means  from 
which  any  benefit  has  been  derived,  is  the  injecting  into  the  vagina 
three  times  a  day,  a  strong  decoction  of  cortex  granati,  or  of  cor- 
tex quercus,  in  which  alum  is  dissolved  in  the  proportion  of  eight 
or  ten  grains  to  every  ounce  of  it.  This  has  the  double  effect  of 
lessening  the  quantity  of  the  discharge,  and  rendering  it  less  offen- 
sive. The  use  of  anodynes  must  be  resorted  to  for  the  mitigation 
of  pain,  and  the  occasional  symptoms  of  suppression  of  urine,  and 
costiveness,  are  to  be  relieved  by  the  use  of  a  catheter  and  mild 
laxatives.  (5)] 


(•»)  Vide  a  paper  on  the  Cauliflower  excrescence  from  the  os  uteri,  &c.  br 
John  Clarke,  M.  D.    Transact,  of  a  society  for  the  improvement  of  Medical  and 
Chirurgioal  knowledge,  1812.     And  new  Medical  and  Physical  Journal,  Jul} 
1812. 


104 


§  31.  CALCULI. 

Earthy  concretions  are  sometimes  formed  in  the  cavity  of  the 
uterus,  and  produce  the  usual  symptoms  of  uterine  irritation;  and 
Vigarous  considers  them  as  very  apt  to  excite  hysterical  affections. 
As  in  the  bladder  of  urine,  the  constant  presence  of  a  calculus  tends 
to  thicken  its  coats,  so  the  irritation  of  a  stone  in  the  uterus  can  ex- 
cite a  disease  of  the  substance  of  the  womb,  and  produce  ulcera- 
tion, which  may  extend  to  the  rectum.  The  disease  in  question 
is  very  rare,  and  can  only  be  discovered  by  feeling  the  concretion 
with  the  finger,  or  a  probe  introduced  within  the  os  uteri,  which  is 
sufficiently  open  to  permit  of  this  examination.  Nature,  it  would 
appear,  tends  to  expel  the  substance  ;*  and  we  ought  to  co-operate, 
if  necessary,  with  this  tendency.  We  must  also  relieve  suppression 
of  urine,f  or  any  other  urgent  symptom  which  may  be  present. 

§  31.  POLYPI. 

Polypous  tumours  are  not  uncommon,  and  may  take  place  at 
any  age ;  they  are  not,  however,  often  met  with  in  very  young 
women.  They  always  affect,  the  health,  producing  want  of  appe- 
tite, dyspeptic  symptoms,  uneasiness  in  the  uterine  region,  a  vari- 
able swelling  of  the  abdomen,  aching  pain  in  the  back,  bearing- 
down  pains,  tenesmus,  and  a  dragging  sensation  at  the  groins. 
When  these  symptoms  have  continued  some  time,  the  strength  is 
impaired,  and  the  pulse  becomes  more  frequent.  At  first,  there  is 
generally  a  mucous  discharge ;  but  at  length  blood  is  discharged^ 
owing  to  the  rupture  of  some  of  the  veins  of  the  tumour,  or  some- 
times from  the  uterine  vessels  themselves,  and  the  permanent  dis- 
charge not  unfrequently  becomes  foetid.  Mr.  Clark,  in  his  late 
work,  very  properly  notices,  that  the  blood  often  coagulates  over 

*  Gaubius  relates  a  case,  where  it  was  complicated  with  prolapsus  uteri.  After 
a  length  of  time,  severe  pains  came  on,  and  in  an  hour  a  large  stone  was  ex- 
pelled ;  next  da\  a  larger  stone  presented,  but  could  not  be  brought  awaj  until 
the  os  uteri  was  dilated.  From  time  to  time  after  this,  small  stones  were  ex- 
pelled; but  at  last  she  got  completely  well. 

■'■  This  proved  fatal  in  a  child  of  five  years  old-. 


105 

the  polypus,  and  comes  off  like  a  ring.  These  symptoms,  however, 
cannot  point  out  to  a  certainty,  the  existence  of  a  polypus ;  we 
must  have  recourse  to  examination,  by  which  we  discover  that  the 
uterus  is  enlarged,  its  mouth  open,  and  a  firm,  but  generally  move- 
able body  within  it.  If  the  os  uteri  have  not  yet  opened,  so  as  to 
admit  the  finger,  the  diagnosis  must  be  incomplete. 

By  degrees  the  polypus  descends  from  the  uterus,  or  painful 
efforts  are  made  more  quickly  to  expel  the  tumour,  the  body  of 
which  passes  into  the  vagina,*  and  sometimes  occasions  retention 
of  urine. f  The  pedicle  remains  in  utero,  and  the  bad  consequences 
formerly  produced,  still  continue,  except  in  a  few  cases,  where  the 
tumour  has  dropped  off,J  and  the  patient  got  well.  In  such  cases 
it  has  been  supposed  that  the  os  uteri  acted  as  a  ligature ;  and  to 
the  same  cause  is  attributed  the  bursting  of  the  veins,  which  pro- 
duce, in  many  instances,  copious  hemorrhage.  But,  although 
hemorrhage  be  most  frequent  after  the  polypus  has  descended,  yet 
it  may  take  place  whilst  it  remains  entirely  in  utero. 

It  sometimes  happens  that  the  uterus  becomes  partially  invert- 
ed,^ before  or  after  the  polypus  is  expelled  into  the  vagina;  and 
this  circumstance  does  not  seem  to  depend  altogether  on  the  size 

*  In  a  case  which  occurred  to  the  late  Mr.  Hamilton  of  this  place,  the  polypus 
was  expelled  by  labour  pains,  but  the  woman  died  exhausted. — In  a  case  related 
by  Vater,  it  was  expelled  when  the  woman  was  at  stool.  Haller,  Disp.  Chir. 
Tom.  III.  p.  621.  See  also  a  case  in  the  same  work,  p.  611.  by  Schunkius. — 
In  the  patient  of  Vacoussain,  the  polypus  was  expelled  after  severe  pain ;  its 
pedicle  was  felt  to  pulsate  very  strongly,  but  a  ligature  being  applied,  the  tu- 
mour was  cut  off",  lnstanth  the  ligature  disappeared,  being  drawn  up  within 
the  pelvis,  but  on  the  third  day  it  dropped  off.  Mem.  de  l'Acad.  de  Chir.  Tom. 
III.  p.  533. 

■j-  Vide  case  by  Vater,  in  Haller,  Disput.  Chir.  Tom.  III.  p.  621.— In  the  case 
furnished  by  M.  Espagnet,  an  attempt  was  made  to  introduce  the  catheter ;  but 
a  straight  one  being  employed  instead  of  a  curved  one,  or  an  elastic  catheter,  it 
was  found  necessary  previously  to  make  an  incision  in  the  fore  part  of  the  poly- 
pus, which  had  protruded.     Mem  de  l'Acad.  de  Chit.  Tom.  III.  p.  531. 

*  Mem.  de  l'Acad.  de  Chir.  Tom.  III.  p.  532. 

§  Vide  case  by  Goulard,  in  Hist,  de  l'Acad.  des  Sciences,  1732,  p.  42  —Dr. 
Denman,  in  his  engravings,  gives  two  plates  of  inversion,  one  from  Dr.  Hunter's 
Museum,  the  other  from  Mr.  Hamilton. 

15 


106 

of  the  polypus,  or  its  weight.     Polypus  may  also  be  accompanied 
with  prolapsus  uteri.* 

Polypi  may  be  attached  to  any  part  of  the  womb,  to  its  fundus, 
cervix,  or  mouth;  and  it  has  been  observed,  that  there  is  less  ten- 
dency to  hemorrhage,  when  they  are  attached  to  the  cervix,  than 
either  higher  up,  or  to  the  os  uteri  itself.  If  there  be  a  union  be- 
twixt the  os  uteri  and  the  tumour,!  or  if  they  be  in  intimate  con- 
tact, polypus  may  pass  for  inversio  uteri;  but  the  history  of  the 
case,  and  attentive  examination,  will  point  out  the  difference,  which 
will  be  noticed  when  I  come  to  consider  inversion  and  prolapsus 
of  the  uterus.  Here  I  may  only  remark,  that  the  womb  is  sensible, 
but  the  polypus  is  insensible,  to  the  touch,  or  to  irritation  ;  but  it 
should  be  recollected,  that  if  the  polypus  be  moved,  sensation  can 
be  produced  by  the  effect  on  the  womb. 

Polypi  are  of  different  kinds.  The  most  frequent  kind  is  of 
a  firm,  semi-cartilaginous  structure,  covered  with  a  production 
of  the  inner  membrane  of  the  womb ;  and  indeed  it  seems  to 
proceed  chiefly  from  a  morbid  change  of  that  membrane,  and  a 
slow  subsequent  enlargement  of  the  diseased  portion:  for  the  sub- 
stance of  the  uterus  itself  is  not  necessarily  affected.  The  enlarge- 
ment is  generally  greatest  at  the  farthest  extremity  of  the  tumour, 
and  least  near  the  womb;  so  that  there  is  a  kind  of  pedicle  formed, 
which  sometimes  contains  pretty  large  blood  vessels,  and  the  tu- 
mour is  pyriform.  But  if  the  membrane  of  the  uterus  be  affected 
to  a  considerable  extent,  and  especially  if  the  substance  of  the 
uterus  be  diseased,  then  the  base,  or  the  attachment  of  the  polypus, 
is  broad. 

The  vessels  are  considerable,  especially  the  veins,  which  some- 
times burst.  In  every  instance,  I  believe,  if  the  patient  live  long,- 
the  tumour  is  disposed  to  ulcerate.  The  ulcer  is  either  superficial 
and  watery,  or  it  is  hollowed  out,  glossy,  and  has  hard  margins,  or 
it  is  fungous.     The  two  last  varieties  are  most  frequent. 

Some  polypi  are  soft  and  lymphatic,  but  these  are  rare  in  the 
uterus.  Some  are  firm  without,  but  contain  gelatinous  fluid,  or  sub- 

*  Med.  Comment.  Vol.  IV.  p.  228. 

f  Mem.  of  Med.  Society  in  London,  Vol.  V.  p.  12. 


107 

stance  like  axunge  within.     Some  are  solid,  others  cellular,  with 
"Considerable  cavities. 

Polypi  are  hurtful  at  first,  by  the  irritation  they  give  the  uterus, 
and  by  sympathetic  derangement  of  the  abdominal  viscera.  In  a 
more  advanced  stage,  they  are  attended  with  debilitating  and  fatal 
hemorrhage,  and  often  with  febrile  symptoms,  especially  if  the 
discharge  be  offensive,  or  the  surface  ulcerated.  Notwithstanding 
the  existence  of  polypus,  however,  it  is  possible  for  a  woman  to 
conceive.* 

Various  means  have  been  proposed  for  the  removal  of  polypi, 
such  as  excision,  caustic,  or  tearing  them  away ;  but  all  of  these 
are  dangerous  and  uncertain ;  and  therefore  the  only  method  now 
practised,  is  to  pass  a  ligature  round  the  base  or  footstalk  of  the 
polypus,  and  tighten  it  so  firmly  as  to  kill  the  part.  The  ligature 
consists  of  a  firm  silk  cord,  or  a  well  twisted  hemp  string,  properly 
rubbed  with  wax,  or  covered  with  a  varnish  of  elastic  gum.  This 
is  better  than  a  silver  wire,  which  is  apt  to  twist  or  form  little  spiral 
turns,  which  impede  the  operation,  and  may  cut  the  tumour.  It  is 
difficult  to  pass  the  ligature  properly,  if  the  polypus  be  altogether 
in  utero ;  and  it  ought  not  even  to  be  attempted,  if  the  os  uteri  be 
not  fully  dilated.  On  this  account,  if  the  symptoms  be  not  ex- 
tremely urgent,  it  is  proper  to  delay  until  the  polypus  have  wholly, 
or  in  part,  descended  into  the  vagina ;  and  when  this  has  taken 
place,  no  good,  but  much  evil  may  result  from  procrastination.  It 
has  even  been  proposed  to  accelerate  the  descent  of  the  polypus, 
and  produce  an  inversion  of  the  uterus. f 

A  double  canula  has  been  long  employed  for  the  purpose  of 
passing  the  ligature,  one  end  of  which  was  brought  through  each 
tube ;  and  the  middle  portion,  forming  a  loop,  was  carried  over 
the  tumour,  either  with  the  fingers,  or  the  assistance  of  a  silver 
probe  with  a  small  fork  at  the  extremity.  By  practice  and  dex- 
terity, this  instrument  may  doubtless  be  adequate  to  the  object  in 
view ;  but  without  these  requisites,  the  operator  will  be  foiled,  the 

*  In  M.  Guiot's  case,  the  polypus  was  expelled. — M.  Levret  adds  other  caseSj 
Mem.  de  l'Acad.  de  Chir.  Tom.  III.  p.  543. 

f  M.  Baudelocque  observes,  "  Nous  regavdions  ce  renversement  necessaire 
pour  obtenir  la  guerison  de  la  malade."    Hccueil  Period.  Tome  IV.  p.  1 


108 

ligature  twisting  or  going  past  the  tumour,  every  attempt  giving 
much  uneasiness  to  the  patient,  and  not  unfrequently,  after  many 
trials  and  much  irritation,  the  patient  is  left  exhausted  with  fatigue, 
vexation,  and  loss  of  blood.  This  is  very  apt  to  happen,  if  the 
polypus  be  so  large  as  to  fill  the  vagina.  The  process  may  be  fa- 
cilitated by  employing  a  double  canula,  but  the  tubes  made  to  se- 
parate and  unite  at  pleasure,*  by  means  of  a  connecting  base,  or 
third  piece,  which  can  be  adapted  to  them  like  a  sheath.  The 
ligature  is  passed  through  the  tubes,  which  are  to  be  placed  close 
together,  and  no  loop  is  to  be  left  at  the  middle.  They  are  then  to 
be  carried  up  along  the  tumour,  generally  betwixt  it  and  the  pubis. 
Being  slid  up  along  the  finger  to  the  neck  of  the  polypus,  one  of 
them  is  to  be  firmly  retained  in  its  situation  by  an  assistant,  and 
the  other  carried  completely  round  the  tumour,  and  brought  again 
to  meet  its  fellow.  The  two  tubes  are  then  to  be  united  by  means 
of  the  common  base.  The  ligature  is  thus  made  to  encircle  the 
polypus,  and,  if  necessary,  it  may  afterwards  be  raised  higher  up 
with  the  finger  alone,  or  with  the  assistance  of  a  forked  probe. 

When  the  ligature  is  placed  in  its  proper  situation,  it  is  to  be 
gradually  and  cautiously  tightened,  lest  any  part  of  the  uterus  which 
may  be  inverted  be  included.  If  so,  the  patient  complains  of  pain, 
and  sometimes  vomits,  and  if  these  symptoms  were  neglected,  and 
the  ligature  kept  tight,  pain  and  tension  of  the  hypogastrium,  fever 
and  convulsions  would  take  place,  and  in  all  probability  the  woman 
would  die.f  In  some  instances,  however,  the  womb  has  been  in- 
cluded without  a  fatal  effect.J 

*  An  instrument  of  this  kind  is  proposed  by  M.  Cullerier,  and  is  described  by 
M.  Lefaucheux  in  his  Dissert,  sur  les  Tumeurs  Circonscrites  et  Indolentes  du 
tissu  cellulaire  de  la  matrice  et  du  vagin. 

f  Dr.  Denham,  Vol.  I.  p.  94.  mentions  a  young1  lady  who  had  suffered  long 
from  uterine  hemorrhage.  A  polypus  was  found  just  to  have  cleared  the  os 
uteri;  a  ligature  was  applied,  but  as  she  felt  severe  pain,  and  vomited,  it  was 
slackened.  Every  attempt  to  renew  the  ligature  had  the  same  effect.  In  six 
weeks  she  died,  and  it  was  found  that  the  uterus  was  inverted. 

t  M.  Hei'biniaux,  Tom.  II.  obs.  17.  relates  a  case.  The  ligature  seemed  to  act 
on  an  inverted  portion  of  the  womb,  producing  pain,  fever,  and  convulsions ;  it 
was  slackened,  but  afterwards,  notwithstanding  a  renewal  of  dreadful  suffering, 
it  was,  with  a  perseverance  hardly  to  be  commended,  employed  so  as  at  last  to 


109 

Even  when  the  uterus  is  not  included,  fever  may  succeed 
the  operation,  and  he  accompanied  with  slight  pain  in  the  belly  ; 
but  the  symptoms  are  mild,  and  no  pain  is  felt  when  the  ligature  is 
first  applied. 

If  the  first  tightening  of  the  ligature,  by  way  of  trial,  give  no  pain, 
it  is  to  be  drawn  firmly,  so  as  to  compress  the  neck  of  the  tumour 
sufficiently  to  stop  the  circulation.  It  is  then  to  be  secured  at  the 
extremity  of  the  canula;  and  as  the  part  will  become  less  in  some 
time,  or  may  not  have  been  very  tightly  acted  on  at  first,  the  liga- 
ture is  to  be  daily  drawn  tighter,  and  in  a  few  days  will  make  its 
way  through.  After  the  polypus  is  tied,  it  is  felt  to  be  more  tur- 
gid, and  harder ;  and,  if  visible,  it  is  found  of  a  livid  colour,  and 
presently  exhales  a  foetid  smell.  These  are  favourable  signs.  The 
diet  is  to  be  light,  and  all  irritation  avoided  during  the  cure.  The 
bowels  and  bladder  must  be  attended  to,  and,  if  there  be  sympa- 
thetic irritation  of  the  stomach,  soda  water  is  useful,  with  small 
doses  of  laudanum. (w) 

§  33.  MALIGNANT  POLYPI. 

There  are  other  tumours  still  more  dangerous,*  as  they  end  in 
incurable  ulceration,  and  are  so  connected  with  the  womb,  that  the 
whole  of  the  diseased  substance  cannot  be  removed.  These  al- 
ways adhere  by  a  very  broad  base,f  and  cannot  be  moved  freely, 

remove  the  polypus. — Desault  found,  after  having  applied  a  ligature  round  a 
polypus,  and  cut  the  tumour  off  next  day,  that  part  of  the  fundus  uteri  was  at- 
tached to  the  amputated  substance  ;  the  patient  did  well.  Baudelocque  supposes 
that  some  cases,  related  as  examples  of  amputation  ofinverted  uteri,  were  merely 
polypi,  accompanied  with  inversion.     Recueil  Period.  Tom.  IV.  p.  115. 

(«)  The  reader  is  referred  to  the  following  interesting  paper  on  the  subject  of 
the  preceding  article,  viz:  "  Memoir  sur  l'organization  des  polypes  uterus,  &c. 
par  P.  J.  Roux,  Tom.  III.  des  onivres  chirurgicales  de  P.  J.  Desault,  par  Xav.  Bi- 
t  hat,  p.  370. 

*  Vide  Mem.  de  l'Acad.  de  Chir.  Tome  III.  p.  538. — Herbiniaux  Observations, 
Tome  I.  ob.  39. — Baillie's  Morbid  Anatomy,  chap.  xix. — Vigarous,  Malad.  des 
Femmes,  Tome  I.  p.  425. 

|  Dr.  Denman,  Vol.  I.  p.  95.  relates  a  case  of  polypus  with  broad  stem,  which 
was  supposed  to  be  a  cancer  of  the  uterus.    The  ligature  was  applied,  and  is 


110 

or  turned  round  like  the  mild  polypus.  They  are  sometimes  pret- 
ty firm,  but  generally  they  are  soft  and  fungous,  or  may  resemble 
cords  of  clotted  blood.  When  dissected,  they  are  found  to  be  very 
spongy,  with  cells  or  cavities  of  various  sizes;  sometimes  they  are 
laminated.  These,  which  have  been  called  vivaces  by  M.  Levret, 
are  always  the  consequence  of  a  diseased  state  of  the  womb;  but 
they  are  not  always,  as  that  author  supposes,  vegetations  from  an 
ulcerated  surface.  They  do,  however,  very  frequently  spring  from 
that  source,  being  generally  of  the  spongoid  nature.  Occasionally 
they  have  been  mistaken  for  a  piece  of  a  retained  placenta,  and 
portions  of  foetid  fungi  have  been  torn  away,  in  attempts  to  extract 
the  supposed  placenta,  or  ovum. 

The  hypogastric  region  is  tumid,  and  painful  to  the  touch,  even 
more  so  than  the  tumour  itself,  which,  felt  per  vaginam,  is  less  sen- 
sible than  the  womb.  Sometimes  little  pain  is  felt  in  this  disease, 
except  when  the  womb  is  pressed.  The  tumour  often  bleeds,  dis- 
charges a  sanious  matter,  and  may  shoot  into  the  vagina :  but  in 
this  it  differs  from  polypus,  that  it  comes  into  the  vagina  generally 
by  growth,  and  not  by  expulsion  from  the  womb,  which  does  not 
decrease  or  become  empty  as  the  vagina  fills.  The  treatment  must 
be  palliative,  for  extirpation  does  not  succeed,  the  growth  being 
rapidly  renewed.     Opiates  and  cleanliness  are  most  useful. 


§  34.  MOLES. 

Moles*  are  fleshy  or  bloody  substances  contained  within  the 
cavity  of  the  uterus.     They  acquire  different  degrees  of  magni- 

cight  or  nine  days  it  came  away  ;  but  when  the  polypus  was  removed,  another 
substance  nearly  of  the  same  size,  was  found  to  have  grown  into  the  vagina. 
The  woman  died  in  a  month.  I  have  seen  the  common  polypus  combined 
with  an  indurated  thickening  of  the  uterus,  and  fungous  or  flocculent  state  of 
the  cavity.  In  one  case  of  tliia  kind,  the  uterus  and  rectum  freely  communi- 
cated b)'  ulceration.     See  also  some  cases  in  Trans,  of  a  Society,  8tc.  Vol.  HI. 

*  Sandifort  Obs.  Path.  Anat.  lib.  II.  p.  78.— Schmid.  de  Concrement.  Uteri,  in 
Haller's  Disp.  Med.  Tomus  IV.  p.  746. 


Ill 

tude,  and  are  found  of  various  density  and  structure.*  They  may 
form  in  women  who  have  not  born  children,!  or  tneY  may  suc" 
ceed  a  natural  delivery,!  or  follow  an  abortion,  or  take  place  in  a 
diseased  state  of  the  uterus.^  It  is  the  opinion  of  many,  that  these 
substances  are  never  formed  in  the  virgin  state,  and  no  case  that  I 
have  yet  met  with  contradicts  the  supposition.  The  symptoms 
produced  by  moles  are  at  first  very  much  the  same  with  those  of 
pregnancy,  such  as  nausea,  fastidious  appetite,  enlargement  of  the 
breasts,  &c. ;  but  the  belly  enlarges  much  faster,  is  softer,  and 
more  variable  in  size  than  in  pregnancy,  being  sometimes  as  large 
in  the  secoud  month  of  the  supposed,  as  it  is  in  the  fifth  of  the  true 
pregnancy.  Pressure  occasionally  gives  pain.  Petit  observes, 
that  the  tumour  seems  to  fall  down  when  the  woman  stands  erect, 
but  this  is  not  always  the  case.  It  must  be  confessed,  that  the 
symptoms  are  at  first,  in  most  cases,  ambiguous,  nor  can  we  for 
some  time  arrive  at  certainty.  In  general,  the  mass  is  expelled 
within  three  months,  or  before  the  usual  time  of  quickening  in 
pregnancy;  and  more  or  less  hemorrhage  accompanies  the  pro- 
cess, which  is  very  similar  to  that  of  abortion,  and  requires  the 
same  management. j|  Sometimes  the  expulsion  may  be  advanta- 
geously hastened,  by  extracting  the  substance  with  the  finger; 
but  we  must  be  careful  not  to  lacerate  it,  and  leave  part  behind. 
If  the  mole  be  retained  beyond  the  usual  time  of  quickening,  we 
find  that  the  belly  does  not  increase  in  the  same  proportion  as 
formerly,  and  the  womb  does  not  acquire  the  magnitude  it  pos- 
sesses in  a  pregnancy  of  so  many  months  standing.  There  is  also 
no  motion  perceived.     Many  of  the  symptoms  of  mole  may  pro- 

*  Sometimes  the  mass  appears  to  be  putrid,  and  is  expelled  with  great  hemor- 
rhage. Vide  case  by  Dr.  Blackbourn,  Lond.  Med.  Journal,  Vol.  II.  p.  122. — 
Sometimes  it  has  a  kind  of  osseous  covering,  as  in  the  case  by  Hankoph,  in  Hal- 
ler.     Disp.  Med.  IV.  p.  715. 

f  La  Motte,  chap.  vii.  This  chapter  contains  several  useful  cases,  one  of  which 
proved  fatal  from  hemorrhage. 

f  Hoffman.  Opera,  Tomus  III.  p.  182.— Stahl.  Coleg.  Casuale,  cap.  lxxvi. 
p.  797. 

§  With  scirrhus  of  the  uterus,  Haller's  Disp.  Med.  IV.  p.  751  et  753. 

8  Puzos  advises  blood-letting,  Traite,  p.  211.— Vigarous  recommend?  emetics 
and  purgatives,  to  favour  the  expulsion,  Tome  I.  p.  115. 


112 

ceed  from  polypus;  but  in  that  case,  the  breasts  are  flaccid  and 
the  symptoms  indicating  pregnancy  are  much  more  obscure.  The 
os  uteri  is  not  necessarily  closed  in  a  case  of  polypus  ;  whereas 
in  that  of  a  mole,  if  there  have  been  no  expulsive  pains,  it  is  gene- 
rally shut. 

When  a  woman  is  subject  to  the  repeated  formation  of  moles, 
I  know  of  no  other  preventive,  than  such  means  as  improve  and 
invigorate  the  constitution  in  general,  and  the  uterus  in  conse- 
quence thereof.  This  is  of  no  small  importance,  as  a  weak  state 
of  the  uterine  system  predisposes  to  more  formidable  diseases,  and 
may  be  followed  by  scirrhus  of  the  womb  or  of  the  breast.* 

§  35.  HYDATIDS. 

Hydatids  may  also  enlarge  the  womb,  and  these  frequently  arc 
formed  in  consequence  of  the  destruction  of  the  ovum  at  an  early 
period,f  or  of  the  retention  of  some  part  of  the  placenta,  after  de- 

*  In  the  Hist,  of  Acad,  of  Sciences  for  1714,  is  the  case  of  a  woman  who  re- 
ceived a  fall  in  the  third  month  of  pregnancy.  The  belly  however  increased  in 
size  till  the  fifth,  when  it  began  to  lessen.  In  the  sixth  she  was  delivered  of  a  bag, 
as  large  as  the  fist,  with  a  placenta  and  foetus  of  the  size  of  a  kidney -bean.  In 
this  case,  hydatids  were  not  formed  ;  but  in  the  History  for  1715,  is  a  case,  where 
the  woman,  falling  in  the  second  month,  had  the  ovum  converted  into  hydatids, 
which  were  expelled  in  the  tenth  month.  As  hydatids  often  succeed  to  genuine 
pregnancy ;  the  symptoms  may  at  first  be  exactly  the  same  with  those  of  preg- 
nancy, nay,  even  motion  may  be  felt,  but  afterwards  the  child  may  die,  and  hy- 
datids form. — Mr.  Watson  in  the  Phil.  Trans.  Vol.  XLT.  p.  711.  gives  a  case, 
where  there  was,  for  a  long  time  before  the  expulsion  of  hydatids,  a  quantity  of 
blood  discharged  every  night;  pains  at  last  came  on,  and  expelled  many  hydatids. 
In  this  case,  the  symptoms  of  pregnancy  were  evident  from  Nov.  to  Feb.  When 
the  ovum  is  blighted,  the  belly  ceases  to  enlarge  in  the  due  proportion,  and  the 
breasts  become  flaccid. 

•j-Dr.  Denman  gives  an  engraving  of  a  diseased  ovum  :  and  Mr.  Home  relates  a 
case,  where  the  patient,  after  being  attacked  with  flooding,  and  vomiting,  and 
spasm  in  the  abdomen,  died.  On  opening  her,  the  womb  was  found  filled  with 
hydatids,  and  its  mouth  a  little  dilated.  Trans,  of  a  Society,  &c.  Vol.  II.  p.  300. — 
Such  cases  as  I  have  seen  have  been  attended  with  considerable  discharge  ;  but 
as  a  great  part  of  it  was  watery,  it  made  a  greater  appearance  than  the  real  quan- 
tity of  blood  would  have  caused. 

In  a  case  related  by  Valleriola,  p.  91,  the  woman  had  at  first  her  usual  symp- 
tom of  pregnancy,  but  in  the  eighth  month  expelled  hydatids.— Pichart  in  Zod 


US 

livery  or  abortion.  We  possess  no  certain  diagnostic;  when  they 
are  formed  in  consequence  of  coagula,  or  }>ari  of  the  placenta  re- 
maining in  utero,  the  symptoms  must  be  such  as  proceed  from  the 
bulk  of  the  womb,  or  from  its  irritation,  as  if  by  a  polypus  or  mole. 
The  remarks  in  the  preceding  section  are  therefore  applicable 
here  ;  but  in  a  great  majority  of  cases,  hydatids  are  formed  in  con- 
sequence of  the  destruction  of  an  ovum  ;  and  accordingly,  the 
symptoms  at  first  are  exactly  the  same  with  those  of  pregnancy. 
These  cease  when  the  ovum  is  blighted,  and  the  time  when  this 
happens  is  marked  by  the  breasts  becoming  flaccid,  and  the  sick- 
ness and  the  sympathetic  effects  of  pregnancy  going  off.  The  con- 
ception remains,  and  the  belly  either  continues  nearly  of  the  same 
size,  or  if  it  increase,  it  is  very  slowly.  Menstruation  does  not 
take  place ;  but  there  may  occasionally  be  discharges  of  blood  in 
different  degrees,  and  there  always  is  at  one  period  or  other,  a 
very  troublesome  discharge  of  water,  so  that  cloths  are  required, 

Med.  Gall.  an.  3,  p.  73,  relates  a  similar  case,  but  the  hydatids  were  expelled  in 
the  fourth  month  without  hemorrhage.  Other  cases  of  hydatids  are  to  be  found 
in  Tulpius,  lib.  III.  c.  32.  Schenkius,  p.  685.  Mercatus  de  Mulier.  afl'ect.  lib.  III. 
c.  8.  Christ,  a  Veiga  Art.  Med.  lib.  III.  §  10.  c.  13.  relates  an  instance  of  60 
hydatids,  as  large  as  chesnuts,  being  expelled. 

Stalpart  Vander  Wiel,  Tom.  1.  p.  301.  mentions  a  woman  who,  in  the  ninth 
month,  after  enduring  pains  for  three  days,  expelled  many  hydatids,  and  the  pro- 
cess was  followed  by  lochia.  Lossius,  Obs.  Med.  lib.  IV.  ob.  16.  mentions  a  widow 
who  for  several  years  had  a  tumid  belly  :  after  death,  hydatids  were  found  in 
utero.  See  also  Mauriceau's  Observations,  obs.  367.  Ruvsch,  Obs.  Anat.  Chir. 
p.  25.  Albinus  Anat.  Acad.  lib.  I.  p.  69.  and  tab.  III.  fig.  1.  describes  in  an 
abortion,  the  commencement  of  this  change.  The  vesicles  are  not  larger  than 
the  heads  of  pins.  Wrisberg  describes  a  more  advanced  stage  in  Nov.  comment. 
Gotting.  Tom.  IV.  p.  73  ;  and  Sandifort,  in  his  Obs.  Anat.  Path.  lib.  II.  c.  3.  tab. 
VI.  fig.  5.  has  a  case  extremely  distinct.     See  also  Haller  Opusc.  Path.  ob.  48. 

Vigarous,  Malad,  &.c.  Tom.  I.  p.  385,  proposes  mercury  to  kill  the  hydatids. 
lie  knew  an  instance  where  the  woman  discharged  hydatids  always  when  she 
went  a  la  garde-robe.  Mr.  Mills  relates  a  case,  where  the  woman  betwixt  the 
second  and  third  month,  had  symptoms  of  abortion,  and  afterwards,  in  the  fifth 
or  sixth,  expelled  above  three  pints  of  hydatids.  Vide  Med.  and  Phys.  Journal, 
Vol.  II.  p.  44f. 

"When  the  mass  is  expelled,  it  is  found  either  to  consist  entirely  of  small  vesi- 
cles, or  partly  of  vesicles,  and  partly  of  more  solid  remains  of  the  ovum,  or  coagu- 
Ium  of  blood. 

16 


114 

and  even  with  these,  the  patient  is  uncomfortable.  No  motion  is 
perceived  by  the  woman,  and  the  size  of  the  belly  and  state  of  the 
womb  do  not  correspond  to  the  supposed  period  of  pregnancy. 
In  some  instances,  the  health  does  not  suffer ;  in  others  feverish- 
ness  and  irritation  are  produced.  After  an  uncertain  lapse  of  time, 
pains  come  on,  and  the  mass  is  discharged,  often  with  very  con- 
siderable hemorrhage.  This  expelling  process  may  sometimes 
be  advantageously  assisted  by  introducing  the  hand  to  remove  the 
hydatids,  or  to  excite  the  contraction  of  the  womb  ;  but  this  must 
be  done  cautiously,  and  only  when  hemorrhage  or  some  other  ur- 
gent symptoms  occur.  These  must  be  treated  on  general  princi- 
ples. 

In  some  cases,  milk  is  secreted  after  the  hydatids  are  expelled. 
In  others,  a  smart  fever,  with  pain  in  the  hypogastrium,  follows. 
It  requires  laxatives  and  fomentations.  When  hydatids  form  in  a 
blighted  ovum,  their  number  varies  greatly  in  different  cases.  In 
some,  I  have  seen  only  a  little  bit  containing  vesicles,  often  only 
the  under  part  which  had  been  for  some  time  detached  in  a  threaten- 
ed abortion.  In  others,  almost  the  whole  is  changed,  and  the 
mass  much  enlarged.  This,  I  presume,  is  connected  with  the 
womb,  by  the  unchanged  portions  alone;  and  therefore,  in  examin- 
ing the  inner  surface  of  such  a  uterus  after  the  mass  was  expelled, 
we  should  expect  to  find  it  more  or  less  similar  to  the  gravid  state, 
according  to  the  greater  or  less  change  in  the  ovum.  The  relative 
magnitude  of  the  vessels  in  the  two  states  has  not  been  ascertained., 
few  opportunities  being  afforded  of  dissection  in  this  disease. (a;^ 

fxj  Ituysch  in  the  first  volume  of  his  valuable  works,  has  given  two  very 
curious  and  accurate  plates  of  these  hydatids  of  the  placenta  or  uterus.  There  is 
also  a  representation  of  these  vesicles  in  Baillie's  plates  of  Morbid  Anatomy,  exe- 
cuted with  great  truth  and  elegance.  It  is  now  generally  considered  by  natural- 
ists, that  the  hydatids  found  in  the  human  body,  are  a  sort  of  imperfect  animals ; 
and  as  Dr.  Baillie  has  observed,  although  there  may  be  some  difference  between 
them  in  simplicity  of  organization,  this  need  be  no  considerable  objection  to  the 
opinion,  as  life  may  be  conceived  to  be  attached  to  the  most  simple  form  of  or- 
ganization. 

For  further  information  on  the  subject  of  hydatids,  particularly  those  of  the 
uterus,  the  student  is  referred  to  a  paper  by  the  editor,  inserted  in  the  Eclectic 
Repertory,  Vol.  I.  p.  499,  and  seq.  Also  to  Monro's  Morbid  Anatomy  of  the 
human  gullet,  stomach  and  intestines,    Edin.  1811,  p.  255. 


115 

Sometimes  there  is  only  one  large  hydatid,  or,  at  most,  a  very 
few  in  the  womb,  and  the  preceding  remarks  will  also  be  applica- 
ble, in  a  great  measure,  to  this  case.  In  the  advanced  stage,  we 
find  the  belly  swelled,  as  in  pregnancy ;  but  the  breasts,  although 
sometimes  tense,  areoftener  flaccid,  and  no  child  can  be  discover- 
ed in  utero,  nor  does  the  woman  perceive  any  motion.  There 
may  be  pain  in  the  abdomen,  and  obscure  fluctuation  is  discernible 
externally,  whilst  per  vaginam  it  is  more  distinct.  The  neck  of 
the  womb  is  small,  and  the  case  much  resembles  ovarian  dropsy, 
except  that  the  tumour  occupies  the  region  of  the  uterus.  The 
duration  of  this  complaint  is  uncertain ;  but  the  water  is  at  last  dis- 
charged suddenly,  and  after  making  some  exertion.  The  bag  af- 
terwards comes  away,  and  the  process  is  not  attended  with  much 
pain.*  It  is  most  prudent  to  be  patient;  but  if  the  symptoms  be 
troublesome,  the  fluid  can  be  drawn  off  by  the  os  uteri.  This 
disease,  a  solitary  hydatid,  is  oftener  combined  with  pregnancy, 
or  with  a  mole,  than  met  with  alone.  The  first  combination!  is 
not  uncommon,  and  I  have  seen  the  hydatid  expelled  some  weeks 
before  labour.  Hildanus  gives  an  instance  of  the  second,  where 
the  ovum  was  converted  into  a  mole  intimately  connected  to  the 
uterus,  and  complicated  with  a  collection  of  fluid  to  the  extent  of 
six  pounds.  In  this  case,  so  much  irritation  was  given,  as  to  ex- 
haust the  strength,  and  produce  local  inflammation. 

§  36.  AQUEOUS  SECRETION. 

A  different  disease  from  that  described  in  the  last  section,  is  an 
increased  secretion  from  the  uterus  itself,  accompanied  generally 
with  symptoms  of  uterine  irritation;  and  if  the  woman  menstruate, 

*  Hildanus,  I  think,  relates  the  histoiy  of  a  woman  who  was  supposed  to  be 
pregnant,  but  dum  noclu  cummarito  rem  haberet,  a  sudden  inundation  swept  away 
her  hopes. 

f  Hildanus  relates  a  case  of  this  kind  in  his  own  wife,  didcissima  et  charissima 
conjux  mea.  Hydatids  may  also  be  combined  with  pregnancy.  The  same  author 
tells  us  of  a  woman  who,  in  the  fifth  month,  was  delivered  of  a  mola  aquosa,  or 
vesicles  containing  ten  pounds  of  water ;  she  did  not  miscarry,  but  went  to  the 
full  time. 


116 

the  menses  arc  pale  and  watery.  There  may  be  a  constant  stilli- 
cidium  of  water,*  or  from  some  obstructing  cause  the  fluid  may  be 
for  a  time  retained,f  and  repeatedly  discharged  in  gushes ;  I  do 
not  know  to  a  certainty,  that  this  can  take  place  without  some  or- 
ganic affection  of  the  womb,  or  some  substance  within  its  cavity. 
At  the  same  time,  I  have  met  with  this  where  no  hydatids  were 
discharged,  where  the  womb  felt  sound,  and  a  cure  was  at  last  ac- 
complished. We  must  always  examine  carefully,  for  it  may  pro- 
ceed from  hydatids,  or  from  disease,  or  excrescences  about  the  os 
uteri.  If  nothing  can  be  discovered,  we  must  proceed  upon  the 
general  principle  of  improving  the  health,  and  injecting  mild  as- 
tringents. I  need  scarcely  caution  the  practitioner  not  to  confound 
a  discharge  of  urine  from  an  injury  of  the  bladder,  with  this  com- 
plaint.;}; 

§  37.  WORMS. 

Worms^  have  been  found  in  the  uterus,  producing  considerable 
irritation ;  and  generally,  in  this  case,  there  is  a  foetid  discharge. 
We  can  know  this  disease  only  by  seeing  the  worms  come  away. 
It  is  cured  by  injecting  strong  bitter  infusions. 

*  Hoffman  mentions  a  woman  who  had  a  constant  stillicidium,  a  pint  being  dis- 
charged daily.     It  at  last  proved  fatal.     Opera,  Tom.  III.  p.  160. 

|  Kirkringius,  p.  28.  considers  dropsy  of  the  uterus  as  impossible,  and  says, 
that  every  case  of  collection  of  water  depends  on  a  large  hydatid.  Dr.  Denman 
seems  to  be  much  of  the  same  opinion.  But  we  find  instances  where  water  is 
accumulated  and  repeatedly  discharged,  apparently  from  the  removal  of  a  tem- 
porary obstruction.  Fernelius  relates  a  case,  where  the  woman  always  before 
menstruation  discharged  much  water.  Path.  lib.  VI.  c.  15.  And  M.  Geoffroy 
describes  a  case  of  repeated  discharge.  Vide  Fourcroy  la  Med.  Eclaree,  Tom. 
II.  p.  287  A  case  is  related  by  Turner,  where  the  external  membrane  of  the 
uterus  was  said  to  be  distended  with  water.  The  menses  were  suppressed,  and 
a  secretion  of  whitish  fluid  took  place  from  the  breasts.    Phil.  Trans.  No.  207. 

$  Vesalius,  Tom.  I.  p.  438,  says,  that  he  found  a  uterus  containing  180  pints  of 
fluid,  and  its  sides  in  many  places  scirrhous.  1  wish  he  may  not  have  mistaken 
the  ovarium  for  the  womb. 

§  Vigarous,  Malad.  Tome  1.  p.  412. — Mr.  Cockson  mentions  a  case,  where  mag- 
gots were  discharged  before  the  menstrual  fluid.  The  woman  was  cured,  by 
injecting  oil,  and  infusion  of  camomile  flowers.    Med.  Comment.  Vol.  HI.  p.  86, 


117 


§  38.  TYMPANITES. 


Sometimes*  air  is  secreted  by  the  uterine  vessels,  and  comes 
away  involuntarily,  but  not  always  quietly.  Tonics,  and  astringent 
injections,  occasionally  do  good  ;  and,  as  this  disease  rarely  causes 
sterility,  it  is  sometimes  cured  permanently  by  pregnancy.  It  is 
said,  that  the  air  is  in  certain  cases,  retained,  and  the  uterus  dis- 
tended with  it,  producing  a  tympanitis  of  the  uterus. 


§  39.  PROLAPSUS  UTERI. 

The  prolapsus,  or  descent  of  the  uterus,  takes  place  in  various 
degrees.f  The  slightest  degree,  or  first  stage,  has  been  called  a 
relaxation  ;  a  greater  degree,  a  prolapsus ;  and  the  protrusion  from 
the  external  parts,  a  procidentia.  It  is  necessary  to  attend  care- 
fully to  this  disease,  to  ascertain  its  existence,  as  it  may,  if  neglect- 
ed, occasion  bad  health,  and  many  uneasy  sensations.  The  symp- 
toms at  first,  if  it  do  not  succeed  parturition,  are  ambiguous,  as 
some  of  them  may  proceed  from  other  causes.  They  are  princi- 
pally pain  in  the  back,  groins,  and  about  the  pubis,  increased  by 
walking,  and  accompanied  with  a  sensation  of  bearing  down. 
There  is  a  leucorrheal  discharge,  and  sometimes  the  menses  are 
increased  in  quantity.  In  a  more  advanced  state,  there  is  stran- 
gury, or  the  urine  is  obstructed,  and  the  patient  feels  a  tumour  or 
fulness  toward  the  orifice  of  the  vagina,  with  a  sensation  as  if  her 
bowels  were  falling  out,  which  obliges  her  instantly  to  sit  down,  or 
to  cross  her  legs,  as  if  to  prevent  the  protrusion.  This  is  accom- 
panied with  a  feeling  of  weakness.  There  are  also,  during  the 
whole  course  of  the  complaint,  but  especially  after  it  has  continued 
for  some  time,  added  many  symptoms,  proceeding  from  deranged 
action  of  the  stomach,  and  bowels,  together  with  a  variety  of  those 
called  nervous.     On  this  account,  an  inattentive  practitioner  may 

•  Vide  Vigarous'  Maladies,  Tome  I.  p.  401. 

t  Vide  Memoir  by  Sabatier,  mod.  vol.  of  the  Memoirs  of  the  Academy  of  Sur- 
gery. 


118 

obstinately  consider  the  case  as  altogether  hysterical,  until  emacia- 
tion and  great  debility  are  induced. 

But  if  the  woman  have  been  recently  delivered,  there  is  less  like- 
lihood of  the  practitioner  being  misled.  She  feels  a  weight  and 
uneasiness  at  the  pubis  and  hypogastric  region,  with  an  irritation 
about  the  urethra  and  bladder;  and  sometimes  a  tenderness  in  the 
course  of  the  urethra,  or  near  the  vulva.  A  dull  dragging  pain  is 
felt  at  the  groins,  and  when  she  stands  or  walks,  she  says  she  feels 
exactly  as  she  did  before  the  child  was  born,  or  as  if  there  was 
something  full  and  pressing.  Pains  are  felt  in  the  thighs,  and  the 
back  is  generally  either  hot,  or  aches.  These  symptoms  go  off  in 
a  great  measure,  when  she  lies  down,  though,  in  some  cases,  they 
are  at  first  so  troublesome,  as  to  prevent  rest.  In  some  instances, 
no  pain  is  felt  in  the  back;  but  whenever  the  patient  stands,  she 
complains  of  a  painful  bearing-down  sensation,  or  sometimes  of 
pressure  about  the  urethra,  or  orifice  of  the  vagina. 

By  examination,  the  uterus  is  felt  to  be  lower  down  than  usual, 
and  the  vagina  always  relaxed.  In  certain  circumstances,  it  pro- 
lapses, forming  a  circular  protrusion  at  the  vulva.  Next,  the  os  uteri 
descends  so  low  as  to  project  out  of  the  vagina.  In  the  greatest 
degree,  or  procidentia,  the  uterus  is  forced  altogether  out,  invert- 
ing completely  the  vagina,  and  forming  a  large  tumour  betwixt  the 
thighs.  The  intestines  descend*  lower  into  the  pelvis,  and  even 
may  form  part  of  the  tumour,  being  lodged  in  the  inverted  vagina, 
giving  it  an  elastic  feel.  In  some  instances,  this  unnatural  situa- 
tion of  the  bowels  gives  rise  to  inflammation.  The  uterus  is  par- 
tially retroverted,  for  the  fundus  projects  immediately  under  the 
perineum,  and  the  os  uteri  is  directed  to  the  anterior  part  of  the 
tumour.  The  orifice  of  the  urethra  is  sometimes  hid  by  the  tu- 
mour, and  the  direction  of  the  canal  is  changed ;  for  the  bladder, 


*  Sometimes  the  situation  of  the  abdominal  viscera  is  very  much  altered.  In 
Mr.  White's  case,  the  liver  was  found  to  descend  to  the  lower  part  of  the  belly, 
and  the  diaphragm  was  lengthened  so  as  to  allow  the  stomach  to  reach  the  umbi- 
lical region.  Vide  Med.  Obs.  and  Inq.  Vol.  III.  p.  1.  In  a  complicated  case,  re- 
latcxl  by  Schliucker,  the  pylorus  hung  down  to  the  pubis.  Haller,  Disp.  Med. 
IV.  4&. 


119 

ii'  it  be  not  scirrhous,  or  distended  with  a  calculus  of  large  size,  i3 
carried  down  into  the  protruded  parts;*  and  a  catheter  passed  into 
it,  must  be  directed  downwards  and  backwards.  The  procidentia 
is  attended  with  the  usual  symptoms  of  prolapsus  uteri,  and  also 
with  difficulty  in  voiding  the  urine,  tenesmus,  and  pain  in  the  tu- 
mour. If  it  have  been  long  or  frequently  down,  the  skin  of  the  va- 
gina becomes  hard,  like  the  common  integuments,  and  it  very  ra- 
pidly ceases  to  secrete.  The  mouth  and  neck  of  the  womb  also,  in 
such  cases,  elongate.  Sometimes  the  tumour  inflames,  indurates, 
and  then  ulceration  or  sloughing  takes  place.  This  procidentia 
may  occur  in  consequence  of  neglecting  the  first  stage,  and  the 
uterus  is  propelled  with  bearing-down  pains ;  or  it  may  take  place 
all  at  once,  in  consequence  of  exertion,  or  of  getting  up  too  soon 
after  delivery.  It  may  also  occur  during  pregnancy,  and  even 
during  parturition.  Sometimes  it  is  complicated  with  stone  in  the 
bladder,f  or  with  polypus  in  the  uterus.J 

Some  have,  from  theory,  denied  the  existence  of  prolapsus,^ 
and  others  have  disputed  whether  the  ligaments  were  torn  or  re- 

*  This  point  is  very  well  considered  by  Verdier,  in  his  paper  on  Hernia  of  the 
Urinary  Bladder,  in  the  first  Vol.  of  Mem.  de  l'Acad.  de  Chir.  See  also  a  paper 
by  M.  Tenon,  in  Mem.  de  l'lnstitute,  Tom.  VI.  p.  614. — Mr.  Paget  relates  a 
very  interesting  case  of  prolapsus  uteri,  in  which  the  bladder  became  retrovert- 
ed,  lying  above  the  uterus.  It  could  not  descend  before  it,  or  along  with  it, 
being  filled  with  a  calculus,  weighing  27  ounces,  and  others  of  a  smaller  size. 
Some  parts  of  the  bladder  were  an  inch  thick  ;  a  catheter  could  not  be  intro- 
duced.    Med.  and  Phys.  Journal,  Vol.  VI.  p.  391. 

f  Ruysch,  feeling  some  hard  bodies  in  the  tumour  formed  by  the  protruded 
parts,  cut  out  42  calculi  from  the  bladder.  M.  Tolet  extracted  fifty,  and  after- 
wards cured  the  woman  with  a  pessary.  Duverncy  met  with  large  calculus  in 
the  bladder,  with  procidentia  uteri ;  and  Mr.  Wbyte  relates  a  similar  fact.  Med- 
Obs.  and  Inq,  Vol.  111.  p.  1.  Sec  also  Deschamps  Traite  de  la  Taille,  Tom.  IV. 
p.  158. 

i  Vide  the  case  of  a  girl  aged  21  years,  related  by  Mr.  Fynney.  The  poly- 
pous excrescence  was  extirpated  from  the  os  uteri,  and  then  a  pessary  was  em- 
ployed.   Med.  Comment.  Vol.  IV.  p.  228. 

§  Kirkringius  says,  Nemo  vidit  nemo  sensit  ckcepli  omnes  imagine  falsa,  alios  deci- 
piunt ;  laxitas  quadum  colli  qua  extra  pudendum  prominet  fuze  nobis  fecil  ludibrio. 
Opera,  p.  48.  Vide  also  Job  a  Meckren,  Observ.  Chir.  c.  51.  Barbette  Chirurg. 
OS  8.    Roonhuysen,  Obs.  Chir.  part  I.  ob.  2. 


120 

laxed.  There  can  be  little  doubt,  that  when  it  occurs  speedily- 
after  delivery,  it  is  owing  to  the  weight  of  the  womb,  and  the  re- 
laxed state  of  the  ligaments  and  vagina.  From  these  causes,  getting 
up  too  soon  into  an  erect  posture,  or  walking,  may  occasion  pro- 
lapsus, particularly  in  those  who  are  weak  or  phthisical.  When  it 
occurs  gradually  in  the  unimpregnated  state,  it  is  rather  owing  to  a 
relaxation  of  the  vagina,  and  parts  in  the  pelvis,  than  elongation  of 
the  round  ligaments.  By  experiments  made  on  the  dead  subject, 
we  find,  that  more  resistance  is  afforded  to  the  protrusion,  by  the 
connection  of  the  uterus  and  vagina  to  the  neighbouring  parts,  than 
by  the  agency  of  the  ligaments  ;  for  although  the  ligaments  be  cut, 
we  cannot,  without  much  force,  make  the  uterus  protrude.  Fre- 
quent parturition,  fluor  albus,  dancing  during  menstruation,  and 
whatever  tends  to  weaken  or  relax  the  parts,  may  occasion  pro- 
lapsus. Sometimes  a  fall  brings  it  on.  No  age  is  exempt  from  it.* 
When  symptoms  indicating  prolapsus  uteri  manifest  themselves, 
we  ought  to  examine  the  state  of  the  womb,  the  patient  having 
lately  been,  or  rather  being,  in  an  erect  posture.  The  symptoms 
sometimes  at  first  turn  the  attention  rather  to  the  bladder  or  pubis, 
than  the  womb ;  but  a  practitioner  of  experience  will  think  it  in- 
cumbent on  him  to  ascertain  the  real  situation  of  that  viscus.  If  we 
find  that  there  is  a  slight  degree  of  uterine  descent,  we  must  imme- 
diately use  means  to  remove  the  relaxation.  These  consist  in  the 
frequent  injection  of  solution  of  sulphate  of  alum  in,  either  in  water, 
or  decoction  of  oak  bark,  repeated  ablution  with  cold  water,  tonics, 
and  the  use  of  the  cold  bath,  at  the  same  time  that  the  bowels  are 
kept  regular,  all  exertion  avoided,  and  a  recumbent  posture  much 
observed.  If  these  things  fail,  or  if  the  disease  exist  to  a  consider- 
able degree,  then,  besides  persisting  in  them,  we  must  have  re- 
course to  the  assistance  of  mechanical  means.  These  consist  of 
supporting  substances  called  pessaries,  which  are  placed  in  the 
vagina,  and  resting  on  the  perineum,  keep  up  the  womb.     They 

*  Dr.  Monro  mentions  a  procidentia  uteri,  in  a  very  young  girl.  It  was  pre- 
ceded by  bloody  discharge.  Works,  p.  535.  Another  case  is  related  by  Saviard, 
Obs.  15.  in  which  the  prolapsed  uterus  was  mistaken  for  the  male  penis ;  and  as 
Goldsmith's  soldier  believed  they  would  allow  him  to  be  born  in  no  parish,  so  this 
girl  was  in  danger  of  being  determined  to  have  no  sex. 


121 

always  give  immediate  relief;  but  where  the  relaxation  is  con- 
siderable, they  only  mitigate,  but  do  not  entirely  remove  the  sen- 
sation, which  must  continue  more  or  less,  as  long  as  the  relaxation 
remains.  It  must  also  be  remembered,  that  they  generally  excite 
a  mucous  discharge  from  the  vagina ;  on  which  account,  as  well 
as  from  the  dislike  many  patients  have  to  them,  they  are  seldom 
employed  in  the  commencement  of  the  complaint,  or  till  other 
means  have  failed.  In  recent  cases,  or  where  the  relaxation  is  not 
great,  a  perseverance  in  the  use  of  the  pessary,  topical  astringents, 
and  general  tonics,  may  accomplish  a  cure.  Fatigue  or  exertion 
must  always  be  avoided.  The  liberal  use  of  tincture  of  kino  in- 
ternally, has  been  advised,  to  act  as  an  astringent  on  the  vagina 
and  muscles,  at  the  outlet  of  the  pelvis ;  but  topical  applications 
are  more  effectual.  Osiander  advises  the  insertion  of  a  bag  of 
fine  linen,  filled  with  powdered  oak  bark,  at  the  same  time  that  the 
patient  is  confined  for  three  weeks  to  bed.  Much  relief  is  obtained 
by  the  use  of  the  spring-support,  immediately  to  be  spoken  of. 

Pessaries  are  made  of  wood,  and  are  of  different  shapes,  some 
oval,  some  flat  and  circular,  some  like  spindles,  or  the  figure  of 
eight,  others  globular.  Of  all  these,  the  globular(yJ  pessary  is  the 
best,  and  it  ought  to  be  of  such  size  as  to  require  a  little  force  to 
introduce  it  into  the  vagina;  that  is  to  say,  it  must  be  so  large  as 
not  to  fall  through  the  orifice,  when  the  woman  moves  or  walks. 
Whichever  be  employed,  it  ought  to  be  taken  out  frequently,  and 
cleaned.*     By  diminishing  gradually  the  size  of  the  pessary,  and 

CyJ  The  oval  form  is  nevertheless  preferred  by  many,  and  apparently  not 
without  reason. 

*  Morand  relates  the  case  of  a  woman  who  had  foetid  discharge  from  the  va- 
gina, accompanied  with  pain.  On  examination,  fungous  excrescences  were  dis- 
covered in  the  vagina,  and  amongst  these  a  hard  substance,  which  being  extracted 
was  found  to  be  part  of  a  silver  pessary.  The  vagina  contracted  at  this  spot,  and 
thus,  though  in  a  disagreeable  way,  prevented  a  return  of  the  prolapsus.  Pessa- 
ries have  also  ulcerated  through  to  the  rectum  ;  and  Mr.  Blair  mentions  a  woman 
in  the  Locke  Hospital,  who  had  introduced  a  quadrangular  piece  of  wood  into 
the  vagina  as  a  pessary,  and  which  ulcerated  through  into  the  rectum,  producing 
great  irritation.  Med.  and  Phys.  Journal,  Vol.  X.  p.  491.  It  is  likewise  necessary, 
if  the  pessary  have  an  opening  in  it,  to  observe  that  the  cervix  uteri  do  not  get 
into  the  opening,  and  become  strangulated. 

17 


122 

using  astringents,  we  may  perhaps  be  able  at  last  to  dispense  with 
it.  In  all  the  stages,  a  firm  broad  bandage  applied  round  the  ab- 
domen, frequently  relieves  the  uneasy  sensations  about  the  bowels, 
back,  and  pubis.  The  cold  bath  is  also  useful.  It  is  farther  ne- 
cessary to  mention,  that  the  symptoms  and  treatment  of  prolapsus 
may  be  modified  by  circumstauces  which  precede  it,  but  with 
which  it  is  not  essentially  connected.  For  instance,  a  tender  or 
inflamed  state  of  the  uterus,  and  the  appendages,  may  take  place 
after  delivery,  and  when  convalescent,  the  patient  may  rise  too 
soon,  or  sit  up,  striving  to  make  the  child  suck,  and  thus  bring  on 
a  degree  of  prolapsus.  In  this  case,  it  is  evident  that  the  symp- 
toms may  be  more  acute  or  painful,  and  they  will  not  be  removed 
by  a  pessary,  until  by  continued  rest,  laxatives,  and  occasional 
fomentations,  the  morbid  sensibility  of  the  parts  within  the  pelvis 
be  got  rid  of. 

When  the  relaxation  is  great,  it  has  been  proposed  to  use  a  hol- 
low elliptical  pessary,  so  large,  as  that  by  pressing  against  the  sides 
of  the  vagina,  it  may  support  both  itself  and  the  womb,  but  it 
generally  gives  pain,  and  the  relaxed  vagina  turns  up  within  it,  and 
becomes  irritated.  I  am  therefore  clearly  of  opinion,  that  the 
oval  pessary  should,  though  hollow,  have  no  large  aperture.  The 
long  diameter  must  vary  from  2\  to  3|  inches,  according  to  the 
degree  of  relaxation.  In  such  cases  of  relaxation,  if  the  oval  pes- 
sary do  not  succeed  in  removing  the  distressing  sensation  of  the 
abdominal  viscera  being  about  to  fall  out,  then,  in  addition  to  it, 
or  the  globe  pessary,  benefit  may  be  derived  from  supporting  the 
perineum  itself,  with  a  soft  pad,  with  a  spring  on  a  similar  princi- 
ple with  that  used  for  prolapsus  ani.  A  contrivance  of  this  kind, 
or  a  firm  T-bandage  must  be  employed  with  a  globe  pessary,  where 
the  perineum  is  greatly  lacerate d.(z) 

(~zj  In  ni)'  own  practice,  I  have  generally  preferred  the  oval  pessary  of  elastic 
gum,  by  being  applied  transversely  ;  as  regards  the  vagina,  there  is  less  danger 
of  impeding  the  evacuation  of  the  feces  and  urine,  by  pressure  on  the  rectum 
and  neck  of  the  bladder,  or  urethra.  Where  this  cannot  be  procured,  pessaries 
may  be  made  of  silver,  of  the  oval  form  and  hollow,  and  with  care  maybe  found 
to  answer.  But  it  is  probable,  that  the  sponge  pessary,  under  proper  manage- 
ment, will  be  found  to  answer  every  intentien.    This  kind  of  pessary,  appears 


123 

If  a  procidentia  be  large,  and  have  been  of  long  duration,  the 
reduction  of  the  uterus  may  disorder  the  contents  of  the  abdomen, 
producing  both  pain  and  sickness.  In  this  case,  we  must  enjoin 
strict  rest  in  a  horizontal  posture.  The  belly  should  be  fomented, 
and  an  anodyne  administered.  Sometimes  it  is  necessary  to  take 
away  a  little  blood ;  and  we  must  always  attend  to  the  state  of  the 
bladder,  preventing  an  accumulation  of  urine.  When  the  symp- 
toms have  abated,  a  pessary  must  be  introduced*  and  the  woman 
may  rise  for  a  little,  to  ascertain  how  it  fits;  but,  as  in  other  cases, 
she  ought  for  some  time  to  keep  much  in  a  horizontal  posture,  and 
avoid  for  a  still  longer  period  every  exertion.  If  there  have  existed 
inflammation  of  the  displaced  bowels,  during  the  continuance  of 
the  procidentia,  serious  consequences  may  result  from  the  reduc- 
tion, owing  to  the  adhesions  which  have  formed.  Should  there  be 
much  difficulty  and  pain  attending  the  attempt  to  reduce,  it  ought 
not  to  be  persisted  in. 

If  the  tumour,  from  having  been  much  irritated,  or  long  protruded, 
be  large,  hard,  inflamed,  and  perhaps  ulcerated,  it  will  be  impos- 
sible to  reduce  it  until  the  swelling  and  inflammation  be  abated, 
by  a  recumbent  posture,  fomentations,  saturnine  applications,  lax- 
atives, and  perhaps  even  blood-letting.f  After  some  days  we  may 
attempt  the  reduction,  and  will  find  it  useful  previously  to  empty 
the  bladder.  The  reduction,  in  general,  causes  for  a  time  abdo- 
minal uneasiness,  which  sometimes  increases  to  a  great  degree,  ac- 
companied with  constipation,  and  rendering  it  necessary  to  allow 
the  tumour  again  to  come  down.  If  the  uterus  cannot  be  reduced, 
and  be  much  diseased,  it  has  been  proposed  to  extirpate  the  tu- 

first  to  have  been  publicly  recommended  by  Dr.  Haighton,  of  London,  and  Iras 
since  been  approved  and  adopted  by  several  practitioners  of  respectability.  See 
a  paper  on  this  subject,  by  Mr.  Dawson,  in  the  12th  Vol.  of  Lond.  Med.  Phys. 
Journal. 

*  Dr.  Denman  very  properly  advises,  that  a  pessary  should  not  be  introduced 
immediately  after  the  uterus  is  reduced.    Lond.  Med.  Journal,  Vol.  VII.  p.  56. 

j-  M.  Hoin  succeeded  in  reducing  a  very  large,  hard,  and  even  ulcerated  proci- 
dentia, by  fomentations,  res',  and  low  diet.  Mem.  de  l'Acad.  de  Chir.  Tome.IH. 
p.  365. 


124 

mour.  This  has  heen  done,  it  is  true,  with  success  *  but  it  is  ex- 
tremely dangerous ;  for  the  bladder  is  apt  to  be  tiedf  by  the  liga- 
ture, which  is  put  round  the  part ;  and  as  the  intestines  fall  down 
above  the  uterus  into  the  sac,  formed  by  the  inverted  vagina,  they 
also  are  apt  to  be  cutj  or  constricted.  As  a  palliative,  Richter  ad- 
vises the  use  of  a  suspensory  bandage. 

A  prolapsus  uteri  does  not  prevent  the  woman  from  becoming 
pregnant  ;^  and  it  is  even  of  advantage  that  she  should  become  so, 
as  we  thus,  at  least  for  a  time,  generally  cure  the  prolapsus.  But 
we  must  take  care,  lest  premature  labour||  be  excited  ;  for  the 
uterus  may  not  rise  properly,  or  may  again  prolapse,  if  exertion  be 
used. 

Sometimes,  especially  if  the  person  receive  a  fall,1T  or  have  a 
wide  pelvis,  the  uterus  may  prolapse  during  pregnancy,  although 
the  woman  have  not  formerly  had  this  disease.     Our  first  car© 

*  See  Rossuet,  Plater  and  Platner.  Inst.  Chir.  section  1447.  Wedelius  de 
Procid.  Uteri,  c.  4.  Volkamer,  in  Miscel.  Cur.  an.  2.  ob.  226.  Another  case  may 
be  seen  in  Journal  de  Med.  Tom.  LXVIII.  p.  195.  Pare  CEuvres,  p.  970. — Carpus 
extirpated  it  with  success.  Vide  Longii  Epist.  Med.  lib.  II.  epist.  39. — Slevog- 
tius  relates  a  distinct  case,  where  the  womb  was  found  in  the  vagina,  as  if  in  a 
purse.  Dissert.  12. — Benevenius  says  he  saw  a  woman  whose  uterus  sloughed 
off.  De  Mirand.  Morb.  Causis,  cap.  12. — Dr.  Elmer  supposes  he  has  met  with  a 
similar  case.  Med.  Phys.  Journal,  Vol.  XVIII.  p.  344. — The  latest  case  is  related 
by  Laumonier.  The  patient  was  long  subject  to  prolapsus  uteri,  but  at  last  the 
womb,  with  the  vagina,  was  forced  out  so  violently,  that  she  thought  all  her  bow- 
els had  come  out.  At  the  upper  part  of  the  tumour  there  was  a  strong  pulsation. 
It  was  extirpated  chiefly  by  ligature.  The  woman  died  some  years  after  this,  and 
the  womb  was  found  wanting.  La  Med.  Eclaree,  par  Fourcroy,  Tom.  IV.  p.  33. 
M.  Baudelocque,  however,  says,  that  the  uterus  was  only  partially  extirpated 
Vide  Recueil  Period.  Tom.  V.  p.  332. 

|  This  happened  in  Huysch's  case.     Obs.  Anat.  vii. 

t  This  occurred  in  a  case  related  by  Henry,  ab  Heers,  Obs.  Med.  p.  192. 

§  Hervey  relates  a  case,  where  the  tumour  was  as  large  as  a  man's  head,  ulce- 
rated, and  discharged  sanies.  It  wras  proposed  to  extirpate  the  prolapsed  uterus, 
but  the  following  night  a  foetus  was  expelled,  spithama  longitvdine.  Opera,  p.  558. 
See  also  a  case  by  Mr.  Antrobus,  in  Med.  Museum,  Vol.  I.  p.  227. 

H  Vide  Mi-.  Hill's  case,  in  Med.  Comment.  Vol.  IV.  p.  88. 

!  Dr.  Burton  had  a  patient,  who  in  the  fourth  month  of  pregnancy  fell,  and 
was  thereafter  seized  with  suppression  of  urine.  The  os  uteri  was  found  almost 
at  the  orifice  of  the  vagina.  He  drew  off  about  three  quarts  of  urine,  raised  up 
the  womb,  and  introduced  a  pessary.    System,  p.  156. 


12d 

ought  to  be  directed  to  the  bladder,*  lest  fatal  suppression  of  urinef 
take  place.  Our  next  object  is  to  replace  the  uterus,  and  retain  it 
by  rest,  and  a  pessary.  If  it  cannot  be  reduced,;};  the  uterus  must 
be  supported  by  a  bandage,^  until,  by  delivery,  it  be  emptied  of  its 
contents.  It  is  then  to  be  reduced.  The  management  of  prolapsus 
during  labour,  will  be  afterwards  considered. 

If  prolapsus  be  threatened,  or  have  taken  place  after  delivery, 
in  consequence,  for  instance,  of  getting  up  too  soon,  we  must 
confine  the  woman  to  a  horizontal  posture,  till  it  have  regained  its 
proper  size  and  weight ;  and  this  diminution  is  to  be  assisted  by 
gentle  laxatives,  particularly  the  daily  use  of  the  sulphas  potassa? 
cum  sulphure,  in  doses  of  from  two  to  three  drachms.  The  band- 
age formerly  noticed,  is  also  useful  and  comfortable. 

In  some  cases,  the  cervix  uteri  lengthens  and  descends  lower  in 
the  vagina,  though  the  body  of  the  womb  remains  in  situ.  This 
is  not  to  be  confounded  with  prolapsus,  for  it  is  really  a  preterna- 
tural growth  of  part  of  the  uterus ;  and  this  portion,  or  elongation, 
has  been  removed  by  ligature. 

§  40.  HERNIA. 

Inguinal  herniae  of  the  uterus  have  been  long  ago  described  by 
Sennert,  Hildanus,  and  Ruysch,  and  very  lately  by  Lallement, 
This  species  of  displacement  may  occur  in  the  unimpregnated 
state,  and  the  woman  afterwards  conceive ;  or  it  may  take  place 
when  pregnancy  is  somewhat  advanced.  If  it  be  possible  to  reduce 

*  Mr.  Dray  mentions  a  case,  where  in  the  fourth  month  of  pregnancy,  the  wo- 
man was  seized  with  pains,  like  those  indicating  abortion,  accompanied  with  sup- 
pression of  urine.  The  os  uteri  was  very  near  the  orifice  of  the  vagina.  This 
disease  proving  fatal,  the  bladder  was  found  to  be  thickened,  enlarged,  and  in 
part  mortified.    Vide  Med.  and  Phys.  Journal,  Vol.  111.  p.  456. 

f  Reink  mentions  a  woman  who  was  pregnant  of  twins.  In  the  fourth  month 
the  womb  prolapsed,  and  caused  a  fatal  suppression  of  urine.  The  vagina  at 
the  upperpart  was  corrugated  and  inverted.  Haller,Disp.  Chir.  Tom.  111.  p.  585. 

t  See  a  remarkable  case  of  prolapsus  in  the  gravid  state,  where  the  whole 
uterus  protruded,  and  reduction  was  not  accomplished  till  after  delivery,  by  P.  C. 
Fabricius,  in  Haller,  Disp.  Chir.  Tomus  HI.  p.  434. 

§  Ykic  Memoirs  by  M.  Sabatier,  in  Mem.  rte  1'Acsd  <!e  Chir.  Tome  III.  p.  370 


126 

the  uterus,  this  must  be  done ;  and  in  one  stage  an  artificial  en- 
largement of  the  foramen,  through  which  the  uterus  has  protruded, 
may  assist  the  reduction.  If,  however,  gestation  be  far  advanced, 
then  the  incision  may  require  to  be  made  into  the  uterus  when 
pains  come  on,  that  the  child  may  be  extracted.  But  it  has  hap- 
pened, that,  even  in  this  untoward  situation,  the  natural  efforts 
have  expelled  the  child  by  the  vagina,  although  the  uterine  her- 
nia, protruding  by  a  separation  of  part  of  the  abdominal  muscles, 
hung  down  so  low  as  the  knee. 

§  41.  DROPSY  OF  THE  OVARIUM. 

The  ovarium  is  subject  to  several  diseases,  of  which  the  most 
frequent  is  that  called  dropsy.  The  appellation,  however,  is  not 
proper,  for  the  affection  is  not  dependent  on  an  increased  effusion 
of  a  natural  serous  secretion  or  exhalation,  but  is  more  akin  to  en- 
cysted tumours,  and  consists  in  a  peculiar  change  of  structure,* 
and  the  formation  of  many  cysts,  containing  sometimes  watery, 
but  generally  viscid,  fluid,  and  having  cellular,  fleshy,f  or  indurated 
substance  interposed  between  them  frequently  in  considerable 
masses.  They  vary  in  number  and  in  magnitude.  There  is  rarely 
only  one  large  cyst  containing  serous  fluid;  most  frequently  we 
have  a  great  many  in  a  state  of  progressive  enlargement;  the 
small  ones  are  perhaps  not  larger  than  peas,  others  are  as  large  as 
a  child's  head,  whilst  the  one  which  has  made  most  progress  may 
surpass  in  size  the  gravid  uterus  at  the  full  time.  The  inner  sur- 
face of  the  cysts  may  either  be  smooth,  or  covered  with  eminences 
like  the  papillae  of  a  cow's  uterus.J  Their  thickness  is  various,  for 
sometimes  they  are  as  thin  as  bladders,  sometimes  fleshy,  and  an 

*  Le  Dran  says  this  dropsy  always  begins  with  a  scirrhus,  and  is  only  a  symp- 
tom of  it — Dr.  Hunter  says  he  never  found  any  part  of  a  dropsical  ovarium  in  a 
truly  scirrhous  state. 

f  Dr.  Johnson's  patient  had  the  right  ovarium  converted  into  a  fleshy  mass 
weighing  nine  pounds,  and  full  of  cysts.     Med.  Comment   Vol.  VII.  p.  265. 

+  I  have  seen  the  inner  surface  of  the  ovarium  studded  over  with  nearly  two 
dozen  of  large  tumours.  M.  Morand  notices  two  cases,  in  which  a  similar  struc- 
ture obtained. 


127 

inch  thick.  The  fluid  they  contain  is  generally  thick  and  coloured, 
and  frequently  foetid,  and,  in  some  instances,  mixed  with  flakes  of 
fleshy  matter,  or  tufts  of  hair;  occasionally,  it  is  altogether  gelati- 
nous, and  cannot  be  brought  through  a  small  opening.  The  ana- 
lysis of  this  has  not  led  to  any  result  of  practical  utility.  The  male 
testicle  is  subject  to  a  similar  disease.  The  tumour  has  been  seen 
made  up  entirely,  or  in  part,  of  hydatids.* 

The  effects  or  symptoms  of  this  disease  of  the  ovarium,  may  all 
be  referred  to  three  sources,  pressure,  sympathetic  irritation,  and 
action  carried  on  in  the  ovarium  itself.  It  sometimes,  though  not 
often,  begins  with  pretty  acute  pain  about  the  groins,  thighs,  and 
side  of  the  lower  belly,  with  disturbance  of  the  stomach  and  intes- 
tines, and,  occasionally,  syncope.  A  few  patients  feel  pain  very 
early  in  the  mammae;  and  M.  Robert  affirms,  that  it  is  felt  most 
frequently  in  the  same  side  with  the  affected  ovarium.  In  some 
cases  milk  is  secreted.f  But  generally  the  symptoms  are  at  first 
slight,  or  chiefly  dependent  on  the  pressure  or  irritation  of  the 
parts  within  the  pelvis.  The  patient  is  costive,  and  subject  to  piles, 
or  strangury,  which,  in  a  few  instances,  may  end  in  a  complete 
retention  of  urine;  the  bowels  are  inflated,  and  sometimes  one  of 
the  feet  swells.  By  examining,  a  tumour  may  often  be  felt  betwixt 
the  vagina  and  rectum,  and  the  os  uteri  is  thrown  forward  near  the 
pubis;  so  that,  without  some  attention,  the  disease  may  be  taken 
for  retroversion  of  the  womb.  J  In  some  time  after  this,  the  tumour, 

*  Sampson,  in  the  Phil.  Trans.  No.  140,  describes  an  ovarium  filled  with  hyda- 
tids, containing  112  pounds  of  fluid. — Willi  mentions  a  tailor's  wife,  whose  ova- 
rium weighed  above  100  pounds,  and  contained  partly  hydatids,  partly  gelatinous 
fluid.     Haller,  Disp.  Med.  Tom.  IV.  p.  447. 

■fin  a  case  detailed  by  Vater,  the  patient  had  symptoms  of  pregnancy,  secreted 
milk,  and  even  thought  she  felt  motion.  The  belly  continued  swelled,  and  she 
had  bad  health  for  three  years  and  a  half,  when  she  died.  The  abdomen  con- 
tained much  water,  and  the  right  ovarium  was  found  to  be  as  large  as  a  man'b 
head,  containing  capsules,  filled  with  purulent-looking  matter.  The  uterus  was 
healthy,  but  prolapsed,  and  the  ureter  was  distended  from  pressure.  Haller's 
Disp.  Med.  Tom.  IV.  p.  401.  This  was  not  a  case  of  extra-uterine  gestation,  for 
the  ovarium  was  divided  into  cells,  and  had  no  appearance  of  foetus. 

i  Mr.  Home's  case,  related  by  Dr.  Denman,  Vol.  I.  p.  130,  had  very  much  thje 
appearance  of  retroversion. 


128 

in  general,  rises  out  of  the  pelvis,*  and  these  symptoms  go  off.  A 
moveable  mass  can  be  felt  in  the  hypogastric,  or  one  of  the  iliac 
regions.  This  gradually  enlarges,  and  can  be  ascertained  to  have 
an  obscure  fluctuation.  The  tumour  is  moveable,  until  it  acquire 
a  size  so  great,  as  to  fill  and  render  tense  the  abdominal  cavity.  It 
then  resembles  ascites,  with  which  it  in  general  comes  to  be  ulti- 
mately combined.f  Little  inconvenience  is  produced,  except  from 
the  weight  of  the  tumour,  and  the  patient  may  enjoy  tolerable 
health  for  years.  But  it  is  not  always  so,  for  the  tumour  some- 
times presses  on  the  fundus  vesicae,  producing  incontinence  of 
urine,  or  on  the  kidney,  making  part  of  it  to  be  absorbed;  and  it 
often  irritates  the  bowels,  causing  uneasy  sensations,  and  some- 
times hysterical  afTections.J  It  augments  in  size  and  carries  up  the 
uterus  with  it;^  so  that  the  vagina  is  elongated;  and  this  is  espe- 
cially the  case,  if  both  ovaria  be  enlarged.  ||     In  many  instances, 

*  In  some  cases  it  does  not  ascend  out  of  the  pelvis,  or  if  it  do,  the  inferior 
part  of  the  tumour  sinks  again  into  it.  Morgagni  relates  an  instance  where  the 
ovarium  weighed  24  pounds ;  and  the  lower  part  of  it  filled  the  pelvis  so  well, 
that  when  it  was  drawn  out,  it  made  a  noise  like  a  cupping  glass  when  pulled 
away  from  the  skin.     Epist.  39.  art.  39. 

j-  It  may  be  combined  with  effusion  of  water  in  the  abdominal  cavity.  Dr. 
Bosch's  patient  had  16  pints  of  water  in  the  abdomen,  and  both  ovaria  were  en- 
larged so  as  to  weigh  102  pounds.  This  patient  complained  of  great  pain  and 
weight  in  the  lower  belly,  and  over  the  right  hip.  She  was  much  emaciated,  but 
the  menses  were  regular.  When  she  was  tapped,  not  above  two  tea-cupfuls  of 
fluid  were  discharged.  Med.  and  Phys.  Journal,  Vol.  VIII.  p.  444. — Mr.  French 
met  with  a  case  of  ascites  and  dropsy  of  the  ovarium.  The  ovarium  extended 
from  the  pubis  to  the  diaphragm.  This  patient  had  voracious  appetite.  Mem.  of 
Medical  Society,  Vol.  I.  p.  234. 

t  Case  by  Sir  Hans  Sloane,  in  Phil.  Trans.  No.  252. — Dr.  Pulteney's  patient, 
whose  ovarium  weighed  56  pounds,  had  excruciating  pain  in  the  left  side, 
spasms,  and  hysterical  fits.     Mem.  of  Medical  Society,  Vol.  II.  p.  265. 

§  This  point  is  well  considered  by  M.  Voison,  in  the  Recueil  Period.  Tome 
XVII.  p.  371,  et  seq. — The  bladder  may  also  be  displaced,  as  in  the  case  of  Ma- 
demoiselle Argant,  related  by  Portal,  Cours  d'Anat.  Tome  V.  p.  549. 

||  If  only  one  of  the  ovaria  be  enlarged,  or  if  both  be  affected,  but  only  one 
much  increased,  the  uterus  is  often  not  raised,  because  the  ovarium  turns  on  its 
axis,  and  the  uterus  lies  below  it.  In  a  case  with  which  I  was  favoured  by  Dr. 
Cleghorn,  both  ovaria  were  greatly  tumified,  and  could  be  felt  on  each  side  of 
the  navel,  whilst  immediately  beneath  that,  they  seemed  to  be  united  by  a  flat 


129 

however,  the  uterus,  in  place  of  rising,  prolapses,  and  occasions  re- 
peated attacks  of  retention  of  urine,  by  pressure  on  the  orifice  of 
the  bladder.  The  urine  is  not  in  the  commencement  much  di- 
minished in  quantity,  unless  this  disease  be  conjoined  with  ascites; 
and  the  thirst,  at  first,  is  not  greatly  increased.  But  when  the  tu- 
mour has  acquired  a  great  size,  the  urine  is  generally  much  dimi- 
nished or  obstructed.  If,  however,  the  bulk  be  lessened  artificially, 
it  is  often,  for  a  time,  increased  in  quantity,  and  the  health  im- 
proved. This  is  well  illustrated  by  the  case  of  Madame  de  Ros- 
ney,*  who  in  the  space  of  four  years,  was  tapped  twenty-eight 
times ;  for  seven  days  after  each  puncture,  she  made  water  freely, 
and  in  sufficient  quantity  ;  the  appetite  was  good,  and  all  the  func- 
tions well  performed  ;  but  in  proportion  as  the  tumour  increased, 
the  urine,  in  spite  of  diuretics,  diminished,  and  at  last  came  only  in 
drops.  The  woman  generally  continues  to  be  regular  for  a  consi- 
derable time,  and  may  even  become  pregnant. 

In  the  course  of  the  disease,  the  patient  may  have  attacks  of 
pain  in  the  belly,  with  fever,  indicating  inflammation  of  part  of  the 
tumour,  which  may  terminate  in  suppuration,  and  produce  hectic 
fever ;  or  the  attack  may  be  more  acute,  causing  vomiting,  ten- 
derness of  the  belly,  and  high  fever,  proving  fatal  in  a  short  time ; 
but  in  many  cases,  these  symptoms  are  absent,  and  little  distress  is 
felt  until  the  tumour  acquire  a  size  so  great  as  to  obstruct  respira- 
tion, and  cause  a  painful  sense  of  distention.  By  this  time,  the  con- 
stitution becomes  broken,  and  dropsical  effusions  are  produced. 
Then  the  abdominal  coverings  are  often  so  tender,  that  they  cannot 
bear  pressure;  and  the  emaciated  patient,  worn  out  with  restless 
nights,  feverishness,  want  of  appetite,  pain,  and  dyspnoea,  expire?. 

hard  substance  ;  and  when  the  urine  was  long  retained,  a  fluctuation  could  be 
perceived  before  that  part.  Upon  dissection,  a  firm  thick  substance  was  found 
extending  from  the  pubis  to  the  navel,  betwixt  the  ovaria.  This  was  the  uterus 
and  vagina.  The  uterus  itself  was  lengthened,  the  cervix  was  three  inches  long, 
and  all  appearance  of  os  tincx  was  destroyed.  Her  complaints  began  after  be- 
ing suddenly  terrified  :  first  she  felt  severe  pain  in  the  right  groin,  with  weak- 
ness of  the  thigh,  and  soon  afterwards  perceived  a  tumour  in  the  belly,  present 
ly  another  appeared  in  the  left  side.  She  was  tapped  16  times. 
*  Portal,  Cours  d'Anat.  Tome  V.  p.  549. 

18 


130 

The  symptoms  of  this  disease,  all  arising  either  from  pressure  or 
irritation,  must  vary  according  to  the  nature  of  the  parts  most  acted 
on,  and  the  peculiar  sympathies  which  exist  in  the  individual. 
When  we  consider  that,  in  many  instances,  the  whole  constitution, 
as  well  as  different  organs,  may  bear  without  injury,  a  great,  but 
very  gradual  irritation,  it  is  not  surprising  that  this  disease,  which, 
for  a  long  time,  operates  only  mechanically,  should  often  exist  for 
years  without  affecting  the  health  materially,  whilst  in  more  irrita- 
ble habits,  or  under  a  different  modification  of  pressure,  much  dis- 
tress, too  often  referred  to  hysteria,  may  be  produced. 

This  disease  has  sometimes  appeared  to  be  occasioned  by  inju- 
ry done  to  the  uterus  in  parturition,  as  for  instance,  by  hasty  ex- 
traction of  the  placenta ;  or  by  blows,  falls,  violent  passions,  frights, 
or  the  application  of  cold ;  but  very  often,  no  evident  exciting  cause 
can  be  assigned. 

This  disease  is  at  first  sometimes  misunderstood,  from  the  most 
prominent  symptom  often  being  tympanites.  Even  careful  exami- 
nation cannot  always  early  discover  a  tumour  amidst  the  inflated 
intestines.  Afterwards,  fluctuation  is  discernible,  and  the  disease 
may  be  taken  for  ascites,  but  in  general,  the  fluctuation  is  more 
obscure  and  circumscribed,  being  seldom  felt  in  the  lumbar  re- 
gion. 

In  the  first  stage  of  this  complaint,  we  must  attend  to  the  effects 
produced  by  pressure.  The  bladder  is  to  be  emptied  by  the  ca- 
theter, when  this  is  necessary ;  and  stools  are  to  be  procured.  It 
may  be  considered,  how  far,  at  this  period,  it  is  proper  to  tap  the 
tumour  from  the  vagina,  and  by  injections  or  other  means,  endea- 
vour to  promote  a  radical  cure.  When  the  woman  is  pregnant,  and 
the  tumour  opposes  delivery,  there  can  be  no  doubt  of  the  pro- 
priety of  making  a  puncture,*  before  having  recourse   to  the 


*  In  a  case  noticed  by  Dr.  Denman,  the  labour  was  obstructed  until  the  ova- 
rium was  emptied,  by  piercing  it  from  the  vagina.  The  woman  died  six  months 
afterwards.  Introd.  Vol.  II.  p.  74.  In  Dr.  Ford's  case,  related  by  Dr.  Denman, 
the  crotchet  was  employed.  See  also  a  case  by  M.  Baudelocque,  l'Art.  des 
Accouch.  §1964; 


131 

erotchet.faj  But  this  has  only  been  resorted  to,  in  order  to  obvi- 
ate particular  inconveniences,  and  affords  no  rule  of  conduct  in 
other  cases  where  no  such  urgent  reason  exists.  I  am  inclined  to 
dissuade  strongly  from  any  operation  at  this  period,  because  in  a 
short  time  the  tumour  rises  out  of  the  pelvis;  and  then  the  patient 
may  remain  tolerably  easy  for  many  years.  Besides,  the  ovarium 
in  this  disease  contains,  in  general,  numerous  cysts ;  and  as  these, 
in  the  first  stage,  are  small,  we  can  only  hope  to  empty  the  largest. 
Perhaps  we  may  not  open  even  that ;  and  although  it  could  be 
opened  and  healed,  still  there  are  others  coming  forward,  which 
will  soon  require  the  same  treatment.  Puncturing,  then,  can  only 
retard  the  growth  of  the  tumour,  and  keep  it  longer  in  the  pelvis, 
where  its  presence  is  dangerous. 

When  the  tumour  has  risen  out  of  the  pelvis,  we  must,  in  our 
treatment,  be  much  regulated  by  the  symptoms.  The  bowels 
should  be  kept  open,  but  not  loose,  by  rhubarb  and  magnesia, 
aloetic  pills,  cream  of  tartar,  or  Cheltenham  salt.  Dyspeptic 
symptoms  may  sometimes  be  relieved  by  preparations  of  steel, 
combined  with  supercarbonate  of  soda,  or  other  appropriate  medi- 
cines, though  their  complete  removal  cannot  be  expected  so  long 
as  the  exciting  cause  remains.  General  uneasiness  or  restlessness, 
occasionally  produced  by  abdominal  irritation,  may  be  lessened  by 
the  warm  bath,  saline  julap,  and  laxatives  ;  whilst  spasmodic  affec- 
tions are  to  be  relieved  by  foetids ;  and  if  these  fail,  by  opiates.  If, 
at  any  time,  much  pain  be  felt,  we  may  apply  leeches,  and  use  fo- 
mentations, or  put  a  blister  over  the  part ;  or  if  the  activity  be 
great,  general  blood-letting  may  be  required.  Upon  the  supposi- 
tion of  this  disease  being  a  dropsy,  diuretics  have  been  prescribed, 
but  not  with  much  success,*  and  often  with  detriment.  Some  have 


{aj  Where  the  tumour  in  the  vagina  occupies  a  large  space,  Dr.  Merriman 
thinks  it  a  warrantable  practice  to  remove  it  by  excision  if  it  consisted  of  a  solid 
substance,  and  certainly  to  puncture  it  if  it  contained  a  fluid.  Vide  Medico-Chi- 
rurgical  Transactions,  Vol.  HI.  p.  47. 

*  Dr.  Denman  justly  observes,  that  diuretics  have  no  effect,  Vol.1,  p.  122.  And 
Dr.  Hunter  remarks,  that  "  the  dropsy  of  the  ovarium  is  an  incurable  disease, 
"  and  that  the  patient  will  have  the  best  chance  for  living  longest  under  it,  who 


132 

supposed,  that  diuretics  do  no  good  whilst  the  disease  is  on  the  in- 
crease ;  but  that,  when  it  arrives  at  its  acme,  they  are  of  service. 
But  this  disease  is  never  at  a  stand ;  it  goes  on  increasing,  till  the 
patient  is  destroyed.     When  they  produce  any  effect,  it  is  chiefly 
that  of  removing  dropsical  affections  combined  with  this  disease ; 
and  in  this  respect,  they  are  most  powerful,  immediately  after  pa- 
racentesis.    With  regard  to  the  power  of  diminishing  the  size  of 
the  ovarium,  my  opinion  is,  that  they  have  no  more  influence  on  it, 
than  they  have  over  a  mellicerous  tumour  on  the  shoulder,  or  over 
the  disease,  when  it  occurs  in  the  testicle.     In  one  case,  fomenta- 
tions and  poultices  appear  to  have  discussed  a  tumified  ovarium  ;* 
and  Dr.  Hamilton  has  lately  stated,  that  he  has  cured  seven  cases 
by  percussion,  or  patting  for  a  length  of  time  daily  on  the  tumour, 
using  a  bandage  so  as  to  make  constant  compression,  giving  solu- 
tion of  muriate  of  lime,  and  employing  the  warm  bath.f  As  some 
tumours  seem  to  diminish,  or  be  absorbed,  under  the  influence  of 
nauseating  medicine,  it  might  be  supposed  that  in  this  formidable 
disease  they  might  be  tried  with  propriety  ;  but  it  may  justly  be 
questioned,  whether  continued  sickness  for  such  a  length  of  time 
as  would  be  required  to  produce  any  sensible  effect  on  the  tumour, 
would  not  be  as  hurtful  at  last  as  the  disease  it  was  meant  to  re- 
move ;  whilst  certainly  during  its  operation  it  is  much  more  dis- 
tressing. 

Having  palliated  symptoms  until  the  distention  becomes  trouble- 
some, we  must  then  tap  the  tumour,  which  gives  very  great  relief; 
and,  by  being  repeated  according  to  circumstances,  may  contribute 
to  prolong  life  for  a  length  of  time.J     As  the  uterus  may  be  car- 


"  does  the  least  to  get  rid  of  it.  The  trocar  is  almost  the  only  palliative."  Med, 
Obs.  and  Inq.  Vol.  II.  p.  41. 

Willi,  however,  relates  a  case  of  14  years  standing,  which  was  cured  by  diu- 
retics ;  and  it  was  calculated  that  the  tumour  contained  100  pounds  of  fluid.  Hal- 
ler,  Disp.  Med.  Tom.  IV.  p.  541. 

*  Vide  Dr.  Monro's  fourth  case,  in  Med.  Essays,  Vol.  V. 

f  Hamilton  on  Mercurial  Medicine,  p.  202. 

\  Dr.  Denman  advises  the  operation  to  be  deferred  as  long  as  possible,  and  I 
believe  he  is  right;  for  every  operation  is  followed  by  re-accumulation,  which  is 
a  debilitating  process ;  yet  it  is  astonishing  how  much  may  in  the  course  of  time 


133 

ried  up  by  the  tumour,  it  is  proper  to  ascertain,  whether  it  bo  the- 
right  ovarium  or  the  left  which  is  enlarged  ;  and  we  should  always 
tap  the  right  ovarium  on  the  right  side,  and  vice  versa :  by  a  con- 
trary practice,  the  uterus  has  been  wounded.*  When  the  disease 
is  combined  with  ascites,  it  is  sometimes  necessary  to  introduce 
the  trocar  twice,  and  the  difference  between  the  two  fluids  drawn 
off  is  often  very  great.  We  must  neither  delay  tapping  so  long  as 
to  injure  by  great  irritation  and  distention,  nor  have  recourse  to  it 
too  early  or  too  frequently,  for  the  vessels  of  the  cavity  excrete 
much  faster  and  more  copiously  after  each  operation  ;  and  it  is  to 
be  remembered,  that  this  is  a  cause  of  increasing  weakness,  not 
only  from  the  expenditure  of  gelatinous  fluid,  but  also  from  the 
increased  action  performed  by  the  vessels,  which  must  exhaust  as 
much  as  any  other  species  of  exertion. 

Finally,  it  has  been  proposed,  to  procure  a  radical  cure,  by  laying 
open  the  tumour,  evacuating  the  matter,  and  preventing  the  wound 
from  healing,  by  which  a  fistulous  sore  is  produced  ;  or  by  intro- 
ducing a  tent,  or  throwing  in  a  stimulating  injection.f     Some  of 

be  secreted,  without  destroying  the  patient.  Mr.  Ford  tapped  his  patient  49 
times,  and  drew  off  2786  pints.  The  secretion  was  at  last  so  rapid,  that  three 
pints  and  three  ounces  were  accumulated  daily.  Med.  Commun.  Vol.  II.  p.  123. 
— Mr.  Martineau  tapped  his  patient  80  times,  and  drew  off  6831  pints,  or  13 
hogsheads ;  at  one  time  he  drew  off  no  less  than  108  pints.  Phil.  Trans.  Vol. 
LXXIV.  p.  471. 

*  In  a  case  of  this  kind  related  by  M.  Voison,  the  uterus  was  wounded,  and  the 
patient  felt  great  pain,  and  fainted.  She  died  on  the  third  day  after  the  opera- 
tion.   Recueil  Period.  Tome  VII.  p.  372,  &c. 

f  Le  Dran  relates  two  cases  in  the  Mem.  de  l'Acad.  de  Chir.  Tom.  HI.  In  the 
first,  the  cyst  was  opened,  and  the  woman  cured  of  the  dropsy,  but  a  fistulous 
opening  remained,  p.  431.  In  the  second,  he  made  a  pretty  large  incision,  and 
introduced  a  canula  into  the  sac.  The  operation  was  followed  by  fever,  delirium, 
and  vomiting ;  the  woman  retained  nothing  but  a  little  Spanish  wine  for  three 
weeks.  She  discharged  daily  8  or  10  ounces  of  red  fluid.  At  length,  all  of  a 
sudden,  15  ounces  of  white  pus  were  evacuated,  and  then  the  symptoms  abated ; 
but  a  fistula  remained  for  two  years  ;  then  it  healed,  p.  442. 

Dr.  Houston  relates  the  case  of  a  woman  in  this  neighbourhood,  in  whom  he 
made  an  incision  2  inches  long  into  the  ovarium,  and  then  with  a  fir  splint  turned 
out  a  great  quantity  of  gelatinous  matter  and  hydatids.  He  kept  the  wound  open 
With  a  tent,  and  succeeded  in  curing  the  pa»ient.     The  disease  was  attributed  to 


134 

these  methods  have,  it  is  true,  been  successful,  but  occasionally 
they  have  been  fatal  ;*  and  in  no  case,  which  I  have  seen,  have 
they  been  attended  with  benefit.  There  are  two  powerful  objec- 
tions to  all  these  practices,  besides  the  risk  of  exciting  fatal  inflam- 
mation :  the  first  is,  that  the  cyst  is  often  irregular  on  its  interior 
surface,  and  therefore  cannot  be  expected  to  adhere;  the  second 
is,  that  as  the  ovarium,  when  dropsical,  seldom  consists  of  one  sin- 
gle cavity,  so,  although  one  cyst  be  destroyed,  others  will  enlarge, 
and  renew  the  swelling ;  and,  indeed,  the  swelling  is  seldom  or 
never  completely  removed,  nor  the  tumour  emptied,  by  one  ope- 
ration. Hence,  even  as  a  palliative,  the  trocar  must  sometimes  be 
introduced  into  two  or  more  places. 

It  has  happened,  that  a  cyst  has  adhered  to  the  intestine,f  and 
burst  into  it,  the  patient  discharging  glairy  or  foetid  matter  by 
stool.J     Such  instances  as  I  have  known,  have  only  been  palliated, 

rash  extraction  of  the  placenta,  and  had  existed  for  thirteen  years.  It  was  at- 
tended with  violent  pains.     Phil.  Trans.  XXXIII.  p.  5. 

M.  Voison  relates  a  case,  which  was  palliated  by  tapping,  and  keeping-  a  fistula 
open.  Recueil  Periodique,  Tom.  XVII.  p.  381.  And  Portal  gives  an  instance, 
where,  by  keeping  the  canula  in  the  wound  for  a  short  time,  a  radical  cure  was 
obtained,  and  the  person  afterwards  had  children.  Cours  d'Anat.  Tom.  V.  p. 
554. 

*  De  La  Porte  tapped  a  woman  who  had  a  large  tumour  in  the  belly,  but  no- 
thing came  through  the  canula.  He  made  an  incision  of  considerable  length, 
and,  in  the  course  of  two  hours  and  a  half,  extracted  35  lb.  of  jelly.  The  lips 
of  the  wounds  were  then  brought  together.  Next  day  15  lb.  of  jelly  were  eva- 
cuated, but  presently  vomiting-  and  fever  took  place ;  and  she  died  on  the  thir- 
tieth day,  having  discharged  altogether  67  lb.  of  fluid.  This  disease  was  of  six- 
teen months  standing,  and  was  attributed  to  hemorrhage.  Mem.  de  l'Acad.  de 
Chir.  Tom.  III.  p.  452. 

Dr.  Denman  notices  the  case  of  a  patient,  who  died  the  sixth  day  after  inject- 
ing the  ovarium.     Vol.  I.  p.  122. 

j"  Dr.  Monro,  in  Med.  Essays,  Vol.  V.  p.  773,  details  the  history  of  a  patient 
who  had  a  diseased  ovarium,  and  in  whom  the  tumour  pointed  about  four  inches 
below  the  navel.  It  was  opened,  but  nothing  but  air  came  out,  followed  next  day 
by  faeces:  on  the  fifth  day  some  pus  was  discharged.  She  gradually  improved 
in  health,  and  the  tumour  of  the  belly  subsided  ;  but  in  two  years  afterwards  the 
suppuration  was  renewed,  and  she  died.  In  this  case,  the  colon  had  probably 
adhered  to  the  ovarium. 

t  Dr.  Denman  relates  the  case  of  a  patient,  who,  having  for  some  time  suffered 
from  pain  and  tenderness  about  the  sacrum  and  uterus,  and  uterine  hemorrhage, 


135 

but  not  cured,  by  this  circumstance.  Sometimes  the  fluid  has 
been  evacuated  per  vaginam,*  or  the  ovarium  has  opened  into 
the  general  cavity  of  the  abdomen,  and  the  fluid  been  effused 
there. 

There  is  another  disease,  or  a  variety  of  the  former  disease,  in 
which  bones,  hair,  and  teeth,  are  found  in  the  ovarium. f  The  sac, 
in  which  these  are  contained,  is  sometimes  large,  and  generally  is 
filled  with  watery  or  gelatinous  fluid.  The  bony  substance,  and 
teeth,  usually  adhere  to  the  inner  surface  of  the  cyst.  This  disease 
produces  no  inconvenience,  except  from  pressure.  It  has  been 
deemed  by  some,  to  be  merely  an  ovarian  conception;  but  it  may 
undoubtedly  take  place  without  impregnation :  nay,  similar  tu- 
mours have  been  found  in  the  male  sex.J  It  is  to  be  treated  as  the 
former  disease. 

was  suddenly  seized  with  vomiting,  syncope,  pains  In  the  belly,  and  costiveness ; 
presently  a  tumour  was  felt  in  the  right  side,  and  this  soon  occupied  the  whole 
abdomen.  This  patient  was  cured,  after  purging  a  gelatinous  fluid.  Med.  and 
Phys.  Jour.  Vol.  II.  p.  20. 

*  Dr.  Monro  relates  a  case  of  supposed  pregnancy,  in  the  tenth  month  of  which 
the  tumour  was  removed  by  an  aqueous  discharge  from  the  vagina.  In  a  future 
attack,  however,  violent  bearing-down  pains  were  excited,  and  the  woman  died 
exhausted.  The  left  ovarium  was  found  greatly  enlarged  with  vesicles.  Med. 
Essays,  Vol.  V.  p.  770. 

j-  See  Dr.  Baillie's  Morbid  Anatomy,  chap.  20.  Dr.  J.  Cleghorn  mentions  a 
woman  who  died  ten  days  after  being  tapped.  The  right  ovarium  was  found 
greatly  enlarged,  and  had  many  cells,  some  containing  hair,  cretaceous  matter, 
fragments  of  bone  and  teeth,  others  gelatinous  fluid.  Trans,  of  Koyal  Irish  Acad. 
Vol.  I.  p.  80.  In  Essays  Phys.  and  Literary,  Vol.  II.  p.  300,  a  case  is  mentioned;, 
in  which  the  one  ovarium  contained  many  vesicles ;  the  other  contained  a  mass, 
like  brain,  with  bones  and  teeth.  In  the  Museum  attached  to  the  hospital  at  Vi- 
enna, there  is  a  large  ovarium,  the  inner  surface  of  which  is  covered  with  hair. 
Hgrstius  met  with  an  ovarium  containing  hair,  purulent-looking  and  oily  matter. 
Opera,  p.  249.  Schenkius  met  with  fat  and  hair,  p.  556,  and  Schacher  relates  a 
similar  case  in  Haller's  Disp.  Med.  Tom.  IV.  p.  477.  Kuysch,  in  his  Adversaria, 
says,  he  met  with  bones  and  hair,  and  Le  Rich,  in  the  Hist,  de  l'Acad.  des  Scien- 
ces,  1743,  met  with  hair  and  oil,  in  cells,  together  with  bones  and  teeth.  See  alscr- 
Recueil  Period.  Tome  XVII.  p.  462. 

$  Duverney  saw  a  tumour  extirpated  from  the  scrotum,  containing  fleshy  mat. 
ter  and  bones.  CEuvres,  Tome  II.  p.  562.  And  M.  Dupuytren  presented  a  re- 
port to  the  Medical  School  at  Paris,  relating  the  history  of  a  tumour  found  in  the 
abdomen  of  a  boy,  containing  a  mass  of  hair,  and  a  foetus  nearly  ossified.    It  was 


13tf 


$  42.  OTHER  DISEASES  OF  THE  OVARIUM. 

The  ovaria  are  sometimes  affected  with  scrophula,  and  the  ti> 
mour  may  prove  fatal  by  producing  retention  of  urine.  When  it 
rises  out  of  the  pelvis,  it  is  often  productive  of  hypochondriasis,  and 
very  much  resembles  the  ovarian  disease,  formerly  mentioned,  but 
is  firmer,  seldom  gives  a  sensation  of  fluctuation,  and  sometimes  is 
very  painful  when  pressed.  It  rarely  terminates  in  suppuration  ; 
but  when  it  does,  the  fluid,  as  Portal  observes,  is  blanchatre,  fila- 
menteux,  grumeleux,  mal  digere.  The  substance  of  the  ovarium  is 
soft,  and  similar  to  that  of  other  scrophulous  glands.  Occasionally 
it  contains  a  cheesy  substance,  which  is  found,  at  the  same  time,  in 
the  mesenteric  and  other  glands.  Burnt  sponge,  cicuta,  mercury, 
electricity,  laxatives,  he.  have  been  employed,  but  seldom  with  be- 
nefit. The  most  we  can  do  is  to  palliate  symptoms,  such  as  re- 
tention of  urine,  costiveness,  dyspepsia,  or  pain. 

The  ovarium  may  also  be  enlarged,  and  become  hard  and 
stony,*  or  converted  into  a  fatty  substance.f  Sometimes  it  is  af- 
fected with  the  spongoid  disease,  and  is  changed  into  a  substance 

supposed,  that  at  conception,  one  germ  had  got  within  another.  See  Edin.  Med. 
Jour.  Vol.  I.  p.  376.  From  the  respectable  evidence  of  Raudelocque,  Le  Roy, 
&c.  this  cannot  be  placed  on  a  footing  with  Halley's  case  of  a  greyhound  dog, 
who  voided  by  the  anus  a  living  whelp  !  Phil.  Trans.  Vol.  XIX.  p.  316.  I  believe 
that  bones,  hair,  &c.  have  been  found  in  a  gelding. 

*  Schlencker  mentions  a  woman,  who,  soon  after  delivery,  felt  obtuse  pain  in 
the  left  side,  and  presently  a  swelling  appeared  in  the  belly.  She  had  bad  appe- 
tite, swelled  feet,  prolapsed  uterus,  and  suppression  of  urine  and  faeces.  The  left 
ovarium  was  hard  and  stony,  and  weighed  three  ounces.  Haller,  Disp.  Med. 
Tom.  p.  419.  In  this  case  the  tumefaction  of  the  belly  could  not  be  caused  by  the 
presence  of  the  ovarium,  but  rather  by  the  pressure  on  the  intestines. 

-j-  Vide  case  by  Fontaine,  in  Haller,  Disp.  Med.  Tom.  IV.  p.  485.  The  patient 
had  tumour  of  the  abdomen,  with  darting  pains  in  the  left  side,  extending  to  the 
thigh.  The  left  ovarium  weighed  10  pounds,  the  right  was  as  large  as  the  fist, 
and  both  consisted  of  fatty  matter.  Portal  likewise  relates  a  case  of  this  disease, 
where  the  right  ovarium  was  as  large  as  a  man's  head,  very  hard,  and  filled  with 
steatomatous  matter,  weighing  altogether  35  pounds.  The  uterus  and  bladder 
were  turned  to  the  left  side.  No  water  was  effused,  but  the  person  was  cut  off 
by  hectic  and  diarrhoea.  Some  steatomatous  concretions  were  found  in  the  lungsv 
t'.ours  d'Anatomie,  Tom.  V.  p.  549. 


137 

like  brain,  with  cysts  containing  bloody  serum..  The  tumour  in 
this  disease,  feels  tense  and  elastic.  It  may  burst  through  the  ab- 
dominal parietes,  and  throw  out  large  fungous  excrescences.  Fre- 
quently we  find,  on  cutting  an  enlarged  ovarium,  that  part  of  it  re- 
sembles the  spongoid  structure,  having  bloody  fungous  cysts  ;  part 
is  like  firm  jelly,  and  part  like  cartilage,  or  dense  fat.  Often  the 
uterus  participates  in  the  disease.  I  have  seen  a  mass  of  this  kind 
weigh  thirteen  pounds.  I  have  never  found  the  ovarium  cancerous.. 

§  43.  DEFICIENCY. 

The  ovaria  may  be  wanting  on  one  or  both  sides,(6)  or  may  be 
unusually  small.  In  such  cases,  it  sometimes  happens,  that  the 
growth  of  the  external  parts  stops  early,  and  the  marks  of  puberty 
are  not  exhibited.  The  ovarium  may  form  part  of  a  heniary 
tumour. 

§  44.  DISEASES  OF  THE  TUBES  AND  LIGAMENTS. 

The  tubes  may  be  wanting,  or  impervious,  and  are  subject  to 
many  of  the  diseases  of  the  ovaria. 

The  round  ligaments  may  partake  of  the  diseases  of  the  uterus, 
or  may  have  similar  diseases,  originally  appearing  in  them.  When 
they  are  affected,  pain  is  felt  at  the  ring  of  the  oblique  muscle,  and, 
sometimes  a  swelling  can  be  perceived  there. 


CHAP.  XI. 

OF  MENSTRUATION. 

The  periodical  discharge  of  sanguineous  fluid,  which  takes 
place  every  month  from  the  uterus,  is  termed  the  menses;  and 

(b)  See  a  case  of  deficiency  of  the  ovaria,  by  Charles  Fears,  F.  L.  S.  in  the 
Phil.  Trans,  for  1805.  This  woman  died  at  the  age  of  twenty-nine.  She  had 
never  menstruated.     She  Mased  to  grow  at  the  age  often  years. 

10 


138 

whilst  the  discharge  continues?-  the  woman  is  said  to  be  out  of 
order,  or  unwell. 

In  some  instances,  the  discharge  takes  place  at  puberty,  without 
any  previous  or  attendant  indisposition;  but  in  most  cases,  it  is 
preceded  by  uneasy  feelings,  very  often  by  affections  of  the  sto- 
mach and  bowels,  pain  about  the  back  and  pelvis,  and  various  hys- 
terical symptoms.  These  affections,  which  are  more  or  less  urgent 
in  different  individuals,  gradually  abate;  but  at  the  end  of  a  month, 
return  with  more  severity,  attended  with  colic  pains,  quick  pulse, 
sometimes  hot  skin,  and  a  desire  to  vomit.  There  now  takes  place 
from  the  vagina,  a  discharge  of  a  serous  fluid,  slightly  red,  but  it 
does  not  in  general  become  perfectly  sanguineous  for  several  pe- 
riods. When  the  discharge  flows,  the  symptoms  abate;  but  fre- 
quently a  considerable  degree  of  weakness  remains,  and  a  dark 
circle  surrounds  the  eye.  In  a  short  time  the  girl  menstruates,  often 
without  any  other  inconvenience  than  a  slight  pain  in  the  back, 
though  sometimes,  during  the  whole  of  her  life,  she  suffers  from 
many  of  the  farmer  symptoms  every  time  she  is  unwell;  and  all 
women,  at  the  menstrual  period,  are  more  subject  than  at  other 
times  to  spasmodic  and  hysterical  complaints. 

When  a  girl  begins  to  menstruate,  certain  changes  tak'i  place, 
denoting  the  age  of  puberty.  The  uterus  becomes  more  expand- 
ed, and  receives  its  adult  form;  the  vagina  enlarges;  the  mons 
veneris  swells  up,  and  is  covered  with  hair;  the  pelvis  is  enlarged; 
the  glandular  substance  of  the  breasts  is  unfolded,  and  the  cellular 
part  increased;  at  the  same  time  the  mental  powers  become  strong- 
er, and  new  passions  begin  to  operate  on  the  female  heart. 

The  age  at  which  menstruation  begins,  varies  in  individuals, 
and  also  in  different  climates.  It  is  a  general  law,  that  the  warmer 
the  climate,  the  earlier  does  the  discharge  take  place,  and  the  soon- 
er does  it  cease.  In  Asia,  for  instance,  the  menses  begin  about 
nine  years  of  age;  whilst  in  the  north,  a  woman  does  not  arrive  at 
puberty  until  she  is  eighteen  or  twenty  years  old;  nay,  if  we  may 
credit  authors,  in  very  cold  countries,  women  only  menstruate  in 
the  summer  seasons.  In  the  temperate  parts  of  Europe,  the  most 
common  age  at  which  the  menses  appear,  is  thirteen  or  fourteen 
years. 


139 

The  quantity  of  the  discharge  varies,  also,  according  to  the  cli- 
mate and  constitution  of  the  woman.  In  this  country,  from  six  to 
eight  ounces  are  lost  at  each  menstrual  period;  hut  this  does  not 
flow  suddenly;  it  comes  away  slowly  for  the  space  of  three  or  four 
days.  Some  women  discharge  less  than  this,  and  are  unwell  for 
a  shorter  space  of  time :  others,  especially  those  who  live  luxu- 
riously, and  are  confined  in  warm  apartments,  menstruate  more 
copiously,  and  continue  to  do  so  for  a  week. 

In  this  country  menstruation  ceases  ahout  the  forty-fourth  year, 
lasting  for  a  period  of  ahout  thirty  years.*  In  the  East  the  menses 
begin  soon,  flow  copiously,  and  end  early;  the  women  in  Asia,  for 
example,  being  old,  whilst  the  Europeans  are  still  in  their  prime. 
In  the  north  the  menses  begin  late,  flow  sparingly,  and  continue 
long. 

The  menses  are  obstructed  during  pregnancy,f  and  the  giving 
of  suck;  but  if  lactation  be  very  long  continued,  the  menses  re- 
turn, and  the  milk  disappears  or  becomes  bad. 

The  discharge  appears  to  be  yielded  by  the  uterine  arteries,  but 
is  not  an  extravasation  or  hemorrhage,  for  when  collected,  it  does 
not  separate  into  the  same  parts  with  blood,  neither  does  it  coagu- 

*  The  periods  of  the  commencement  and  cessation  of  the  menstrual  discharge, 
mentioned  by  our  author,  as  occurring  in  Great  Britain,  agree  pretty  nearly  with 
what  is  observed  to  take  place  in  the  United  States. 

f  This  is  a  point  still  debated.  The  weight  of  authority  is,  however,  decidedly 
against  menstruation  continuing  during  pregnancy.  By  Baudelocque,  Den- 
man,  and  almost  all  the  modern  writers,  it  is  denied.  Those  who  maintain  the 
contrary  opinion,  have  very  probably  mistaken  a  hemorrhage  from  the  vagina, 
which  sometimes  recurs  with  considerable  periodical  regularity,  for  the  men- 
strual flux.  Several  cases  of  this  kind  have  come  under  my  own  observation, 
where  I  had  an  opportunity  of  examining  the  discharge  accurately.  In  every 
inatance,  I  found  it  pure  coagulable  blood. 

By  adverting  to  the  state  of  the  pregnant  uterus,  this  is  exactly  what  we  should 
be  led  to  expect.  Contemporary  with  conception,  we  know  that  the  uterine  ca- 
vity is  lined  with  the  membrana  decidua,  and  that  soon  afterwards  the  os  tines  is 
completely  sealed  with  impacted  mucus.  Were  an  effusion  therefore  to  take 
place,  especially  in  the  early  months  of  gestation,  it  would  destroy  the  attach- 
ment of  the  membrane,  and  produce  all  the  consequences  of  uterine  hemorr- 
hage. 

It  would  seem,  moreover,  that  the  action  which  the  vessels  of  the  uterus  take 
on  to  fabricate  and  support  this  membrane,  is  totally  incompatible  with  the  men- 


140 

late.(e)  In  many  instances  a  great  quantity  has  been  retained  for 
some  months  in  the  uterus  and  vagina,  but  it  never  has  been  found 
clotted  when  it  was  evacuated. 

Menstruation  has  been  attributed  to  the  influence  of  the  moon, 
to  the  operation  of  a  ferment  in  the  blood,  or  in  the  uterus,  to  the 
agency  of  a  general  or  local  plethora,  or  to  the  existence  of  a  se- 
cretory action  in  the  uterus.*     The  last  of  these  is  the  most  pro- 


stata! secretion.  The  two  actions  cannot  co-exist.  This  is  proved  not  only  by 
the  alleged  cessation  of  the  menses  during  pregnancy,  but  still  more  clearly  by 
the  fact  which  has  not  been  sufficiently  attended  to,  that  in  a  large  proportion 
of  cases  of  obstinate  amenorrhea,  the  membrana  decidua  exists,  and  that  the  first 
symptom  of  the  return  of  the  discharge  is  the  coming  away  of  the  membrane. 
Of  the  identity  of  the  two  membranes  there  can  be  no  doubt.  It  has  been  ascer- 
tained by  Dr.  Baillie  and  many  other  competent  judges.     C. 

(~cj  The  celebrated  John  Hunter  was,  perhaps,  the  first  physiologist  who  took 
notice  publicly  of  this  fact,  at  least  in  Great  Britain.  In  his  Lectures  on  the  Theo- 
ry and  Practice  of  Surgery,  (as  quoted  by  Dr.  R.  W.  Johnson,  System  of  Midwife- 
ry, 2d  edition,  4to.  p.  34  and  35)  he  observes,  that  "  the  blood  discharged  in 
menstruation,  is  neither  similar  to  blood  taken  from  a  vein  of  the  same  person, 
nor  to  that  extravasated  by  an  accident  in  any  other  part  of  the  body  ;  but  is  a 
species  of  blood  changed,  separated,  or  thrown  off  from  the  common  mass,  by  an 
action  of  the  vessels  of  the  uterus,  in  a  process  similar  to  secretion  ,-  by  which  ac- 
tion the  blood  having  lost  its  living  principle,  it  does  not  afterwards  coagulate." 
In  his  Treatise  on  the  Blood,  vol.  I.  p.  24,  Philadelphia  edition,  he  says,  "  in 
healthy  menstruation,  the  blood  which  is  discharged  does  not  coagulate  ;  in  the 
irregular,  or  unhealthy,  it  does.  The  healthy  menses,  therefore,  (he  continues) 
show  a  peculiar  action  of  the  constitution  ;  audit  is  most  probably  in  this  action, 
that  its  salubrious  purposes  consist." 

*  I  am  too,  very  much  inclined  to  believe,  that  menstruation  results  from  a  se- 
cretory action  of  the  uterus.  Every  other  theory  on  the  subject  is  indeed  totally 
irreconcilable  with  facts.  I  will  briefly  enumerate  the  leading  arguments  by 
which  the  doctrine  may  be  defended. 

1.  That  the  uterus  in  its  villous  and  vascular  structure  resembles  in  some  de- 
gree a  gland,  aqd  also,  in  its  diseases,  being  equally  liable  to  scirrhus,  cancer,  &c. 
&c. 

2.  That,  like  other  secretory  organs,  blood  is  very  copiously  diffused  through 
it. 

3.  That  by  the  arrangement  of  its  vessels,  it  is  evidently  designed  that  the  cir- 
culation should  be  retarded  for  the  purpose  of  secretion.  The  arteries  are  not 
only  exceedingly  convoluted,  but  they  are  larger  and  with  thinner  coats  than 
their  corresponding  veins.  Thus,  Haller  says,  "  the  blood  is  brought  to  the 
"womb  in  greater  quantity,  and  more  quickly  through  its  lax  and  ample  arteries, 


141 

bable  opinion ;  but  as  this  work  is  meant  to  be  practical,  I  think 
it  wrong  to  devote  more,  time  to  the  discussion  of  theories  and 
speculations.  The  use  of  menstruation  seems  to  be  to  preserve 
the  womb  in  a  fit  state  for  impregnation ;  at  least,  we  know,  that 
the  presence  of  menstruation  is  generally  necessary  to,  and  indi- 
cates a  capability  of,  conception. 


and  on  account  of  the  rigidity  and  narrowness  of  the  veins,  it  returns  with  diffi- 
culty." 

4.  That,  in  common  with  other  secretions,  menstruation  is  often,  at  first,  im- 
perfectly done,  and  is  subject  afterwards  to  vitiation  and  derangement.  At  its 
commencement  the  discharge  is  commonly  thin,  colourless,  and  deficient,  and 
recurs  at  protracted  and  irregular  intervals  with  pain  and  difficulty. 

5.  That,  in  many  of  the  inferior  animals,  during  the  season  of  venereal  incales- 
cence,  there  is  an  uterine  discharge  which  is  undoubtedly  a  secretion.  This  an- 
swers seemingly  the  same  end  as  menstruation,  namely,  giving  to  the  uterus  an 
aptitude  to  conception.  Though  this  tiuid  generally  differs  from  the  menses  in  com- 
plexion, yet  in  some  instances  they  are  precisely  similar.  Whenever  the  vene- 
real desire  suffers  a  violent  exascerbalion  from  restraint,  or  other  causes,  the  dis- 
charge in  these  animals  becomes  red.  This  has  been  more  especially  remarked 
in  bitches  kept  from  the  male. 

6.  That  the  menses  are  a  fluid  sui  generis,  or  at  least  varying  very  essentially 
from  the  blood,  having  neither  its  colour  nor  odour,  nor  coagulability,  and  on  che- 
mical analysis  present  different  results.  These  last  circumstances  are  enough  alone 
to  establish  the  theory. 

7.  To  the  objection  that  the  uterus  is  not  sufficiently  glandular  for  the  function 
of  secretion,  it  has  been,  I  think,  very  satisfactorily  replied,  that  there  is  ;d]y 
a  viscus  or  surface  of  the  body  which  is  not  competent  to  the  secretion  of  a  fluid. 
It  would  really  seem  that  no  operation  of  the  animal  economy  requires  a  less 
complex  apparatus.  Of  what  indeed  does  a  gland  consist,  except  a  congeries  of 
vessels  ?  Even  the  mos;  perfect  of  the  secretions  are  affected  by  this  simple 
contrivance.  If  a  few  vessels,  "  creeping  over  the  coats  of  the  stomach,"  can  se- 
crete the  gastric  liquor,  why  may  not  the  infinitely  more  glandular  organization 
of  the  uterus  elaborate  the  menstrual  fluid  tfdj     C. 

fdj  Saunders  has  been  presumed  by  some,  to  have  been  the  first  who  consi- 
dered the  catamenia  as  a  secretion;  but  Borden,  a  French  physiologist  of  great 
merit  and  of  earlier  date,  treats  of  the  uterus  as  a  gland  ;  and  of  course,  it  is  to 
be  presumed,  must  have  viewed  the  menses  as  a  secreted  fluid.  Haller  also,  in  • 
his  Notes  on  the  Prelectiones  Academical  of  Boerhaave,  [Amstelodami,  A.  D. 
1744,]  speaks  of  the  menses  as  a  secretion.  His  words  are  "  Sed  facile  ipsa  fab- 
rica  partium  demonstrat  uterum  naturale  organum  esse  hujus  secretionis."  Vol. 
VI.  p.  72.  Dr.  Chapman  says,  that  Dr.  Craven  supported  this  opinion,  in  a  The- 
sis published  at  Edinburgh  in  the  year  1778. 


142 

The  action  of  menstruation  has  an  effect  on  the  vascular  and 
nervous  system,  and  on  the  stomach  and  bowels.  All  tender  or 
diseased  parts  are  worse,  and,  if  visible,  their  vessels  are  more  tur- 
gid previous  to  menstruation.  The  nervous  system  is  more  irrita- 
ble, and  convulsive  affections  of  the  body,  or  aberrations  of  mind, 
are  more  frequent  at  this  period  than  at  other  times.  The  stomach 
may  be  affected  with  severe  sickness  and  violent  retching,  or  by 
sympathy  with  the  skin,  may  produce  urticaria,  whilst  the  bowels 
for  a  day  or  two  before  menstruation,  sometimes  are  much  inflated 
and  costive,  or  at  the  period  itself  are  affected  with  spasm. 

As  the  female  system  is  more  irritable  during  menstruation  than 
at  other  times,  and  as  changes  effected  in  the  system,  or  in  parti- 
cular organs,  at  that  time,  may  come  to  interfere  with  the  due 
performance  of  the  uterine  action,  it  is  a  general  and  proper  cus- 
tom with  physicians,  and  a  practice  consonant  to  the  prejudice  of 
women  themselves,  not  to  administer  active  medicines  during  the 
flow  of  the  menses.  It  is  also  proper,  that  indigestible  food,  danc- 
ing in  warm  rooms,  sudden  exposure  to  cold,  and  mental  agita- 
tion, especially  in  hysterical  habits,  be  avoided  as  much  as  pos- 
sible. By  neglecting  these  precautions,  the  action  may  either  be 
suddenly  stopped,  or  spasmodic  and  troublesome  affections  may 
be  excited. 


CHAP.  XII. 


OF  HYSTERIA. 


Although  hysteria  be  not  a  diseased  state  of  menstruation, 
yet,  as  it  is  a  very  general  attendant  upon  deviations  of  that  ac- 
tion, and  a  very  frequent  and  distressing  complaint,  to  which 
women  are  subject,  it  will  be  proper  to  notice  it  briefly  at  this 
time. 

In  the  well  marked  hysteric  paroxysm,  a  sense  of  pain  or  ful- 


143 

ness  is  felt  in  some  part  of  the  abdomen,  most  frequently  about  the 
umbilical  region,  or  in  the  left  side,  betwixt  that  and  the  stomach. 
This  gradually  spreads,  and  the  sensation  of  a  ball  is  felt  passing 
along.  It  mounts  upwards,  and  by  degrees  reaches  the  throat,  and 
impedes  respiration,  so  as  to  give  the  feeling  of  a  globe  in  the  oeso- 
phagus, obstructing  the  passage  of  the  air,  and,  as  Van  Swieten 
observes,  the  throat  appears  sometimes  really  to  be  distended. 
The  patient  now  sinks  down  convulsed,  and  apparently  much  dis- 
tressed in  breathing,  uttering  occasionally,  shrieks,  something  like 
the  crowing  of  a  cock,  or  sobbing  violently,  or  otherwise  indicating 
a  spasm  of  the  muscles  of  respiration.  She  is  generally  pale,  and 
frequently  insensible,  at  least  during  part  of  the  fit,  and  seems  to 
be  in  a  faint ;  but  when  she  recovers,  she  is  conscious  not  only  of 
having  been  ill,  but  of  many  things  which  passed  in  a  state  of  ap- 
parent insensibility.  After  remaining  for  some  time  in  a  state  of 
considerable  agitation  of  the  muscular  organs,  the  affection  abates, 
and  the  patient  remains  languid  and  feeble,  but  gradually  recovers, 
and  presently  is  restored  to  her  usual  health.  This  restoration  is 
accompanied  with  eructation,  which  indeed  often  takes  place  dur- 
ing the  paroxysm;  and  also  by  the  discharge  of  limpid  urine, 
which,  by  Sydenham,  is  considered  as  a  pathognomonic  symptom 
of  hysteria.     Headach  is  also  apt  to  follow  a  fit. 

Besides  producing  these  regular  paroxysms,  hysteria  still  more 
frequently  occasions  many  distressing  sensations,  which  arc  so  va- 
rious, as  not  to  admit  of  description.  Of  this  kind  are  violent  head- 
ach, affecting  only  a  small  part  of  the  head,  sudden  spasms  of  the 
bowels,  dyspncea,  with  or  without  an  appearance  of  croup,  and 
sometimes  attended  with  a  barking  cough,  irregular  chills,  and  sud- 
den flushings  of  heat,  spasmodic  pains,  palpitation,  syncope,  Sec. 
These,  if  severe,  or  frequently  repeated,  are  generally  attended 
with  a  timid  or  desponding  state  of  mind. 

During  an  hysteric  fit,  the  patient  is  to  be  laid  in  an  easy  pos- 
ture, a  free  admission  of  cool  air  is  to  be  procured,  the  face  is  to 
be  sprinkled  with  cold  vinegar  or  Hungary  water,  volatile  salts  are 
to  be  held  to  the  nostrils,  and  if  she  can  swallow,  30  drops  of  tinc- 
ture of  opium  are  to  be  administered,  with  the  same  or  a  greater 
quantity  of  ether,  in  some  carminative  water;  or  should  there  be  a 


144 

tendency  to  syncope,  a  drachm  of  the  spiritus  ammonia?  aromaticus 
may  be  conjoined.  A  similar  combination  of  opium  is  the  most 
powerful  remedy  in  the  different  hysterical  affections  above  enu- 
merated. 

I  may  farther  remark,  1st.  that  local  pain  is  frequently  removed 
by  sinapisms,  with  or  without  the  internal  use  of  opium  ;  2d. 
that  severe  affections  of  the  organs  of  respiration,  particularly  if 
accompanied  with  full  and  frequent  pulse,  are  more  readily  relieved 
by  the  lancet  than  by  antispasmodics ;  and  it  is  a  great  error  to 
suppose  that  the  mere  name  of  hysteria  can  render  a  remedy  im- 
proper, which  both  experience  and  the  general  principles  of  pa- 
thology prove  to  be  worthy  of  confidence  ;  3d.  although  the  lancet 
be  proper  in  urgent  cases,  it  ought  not  to  be  frequently  resorted  to, 
but  the  paroxysms  are  to  be  kept  off  by  a  strict  attention  to  the 
state  of  the  bowels,  and  the  employment  of  foetids,  or  mild  tonics } 
4th.  in  repeated  attacks  of  spasmodic  breathing,  like  croup,  the 
effect  of  an  emetic  may  be  tried  before  again  taking  blood,  parti- 
cularly if  venesection  have  been  recently  employed ;  after  the 
operation  of  the  emetic,  a  suitable  dose  of  tincture  of  opium  may 
be  given,  and  we  delay  the  lancet  till  the  effect  of  these  be  seen. 
In  the  mean  time  the  patient  is  in  no  danger  of  dying ;  5th.  a  state 
of  coma  demands  either  general  or  local  bleeding,  according  to  the 
state  of  the  patient  and  the  previous  depletion ;  6th.  irregular  ac- 
tion of  the  heart,  or  palpitation,  requires,  during  the  attack,  ether 
and  opium ;  but  if  these  fail,  and  the  patient  be  plethoric,  some 
blood  ought  to  be  abstracted. 

The  prevention  of  regular  hysteric  fits,  or  of  individual  symp- 
toms, is  to  be  attempted  by  preserving  a  correct  state  of  the  bowels, 
or  even  giving,  every  day,  pretty  powerful  purges,  the  administra- 
tion of  preparations  of  steel,  or  other  tonics,  moderate  exercise, 
and  the  cold  bath,  if  it  do  not  produce  languor  or  coldness  and 
headach ;  the  mind  ought  also  to  be  called  as  much  as  possible 
from  brooding  over  the  disease,  for  in  hysteria,  the  patient  is  fre- 
quently desponding,  and  anticipating  many  evils.  The  menstrual 
action,  if  irregular,  must,*  if  possible,  be  rectified  by  appropriate  re- 
medies. The  diet  should  be  light,  and  rather  sparing,  and  all  cause? 
of  debility  must  be  avoided.     Foetids  are  sometimes  of  use. 


146 

Hysteria  may  occur  during  the  course  of  other  diseases,  or  in 
the  stage  of  convalescence  from  them.  In  the  first  case,  it  may 
cause  some  deviation  from  the  regular  progress  or  train  of  symp- 
toms of  the  disease,  and,  it  is  to  be  feared,  sometimes  calls  the  at- 
tention of  the  practitioner  from  more  serious  parts  of  the  patient's 
malady. 


CHAP.  XIII. 

Of  Diseased  States  of  the  Menstrual  fiction. 
§  1.  AMENORRHEA. 

Amenorrhea,  or  absence  of  the  menses,  has  been  divided  info' 
the  retention,  or  emansio  mensium,  and  the  suppression  of  the 
menses.  By  the  first  term,  we  are  to  understand,  that  the  menses 
have  not  yet  appeared,  the  action  being  longer  than  usual  of  being 
established.  By  the  second,  is  meant  the  interruption  of  the  ac- 
tion which  has  already  been  established,  and  hitherto  performed. 
This  may  be  subdivided  into  checked  menstruation,  and  prevented 
menstruation,  commonly  called  obstruction. 

The  retention  of  the  menses  is  very  generally  attended  with 
chlorosis,  or  a  feeling  of  weariness  and  debility,  with  dislike  to 
active  employment ;  a  pale  or  sallow  complexion,  cathectic  appear- 
ance, cedematous  swelling  of  the  legs  and  feet  j  costiveness,  dys- 
peptic complaints,  such  as  flatulence,  acidity,  loathing  of  food,  but 
craving  for  indigestible  substances,  as  chalk,  lime,  or  cinders; 
pains  of  the  head,  and  different  parts  of  the  body  ;  swelling  of  the 
belly,  with  hysteric  symptoms,  such  as  palpitation,  or  dyspnoea ; 
and  if  this  state  be  not  soon  removed,  it  is  apt  to  end  either  in 
consumption  or  dropsy. 

The  menses,  may,  from  one  person  not  arriving  so  early  as 
another  at  puberty,  be  longer  of  appearing  in  some  women  than  in 

20 


I4G 

others ;  and  in  such  cases,  no  peculiar  inconvenience  attends  the 
retardation.  But  when  the  retention  proceeds  from  other  causes, 
it  is  to  be  considered  as  a  disease  ;  and  generally,  is  to  be  attributed 
to  a  want  of  vigour  in  the  system ;  by  which,  not  only  a  new  ac- 
tion is  prevented  from  being  formed,  but  also  those  which  were 
formerly  performed,  become  impaired.  In  some  cases,  indeed, 
the  absence  of  the  menses  depends  upon  a  malformation  of  the 
organs  of  generation,  a  deficiency  of  the  ovaria,*  an  imperfect  de- 
velopment of,  or  a  special  want  of  energy  in,  the  uterus ;  but  in 
far  the  greatest  number  of  instances,  the  action  is  postponed, 
merely  from  general  debility  of  the  system;  and  accordingly,  the 
most  successful  mode  of  treatment  consists  in  improving  the  health, 
and  increasing  the  strength  of  the  patient.  This  is  to  be  done  by 
regular  exercise,  proportioned  to  the  ability  of  the  person ;  the 
use  of  the  hot  salt  water  bath  every  day,  succeeded  by  frictions 
with  dry  flannel,  or  a  soft  brush  :  sufficient  clothing,  and  particu- 
larly a  flannel  dress;  a  nourishing  and  digestible  diet,  with  a  pro- 
per portion  of  wine ;  avoiding  every  thing  which  disagrees  or 
ferments ;  the  administration  of  tonic  medicines,  particularly  pre- 
parations of  iron,  such  as  chalybeate  waters,  tincture  of  muriated 
iron,  or  the  carbonas  ferri  precipitatum  combined  with  myrrh. 
Tannin,  to  the  extent  of  a  hundred  grains  in  the  day,  has  also  been 
proposed.  The  use  of  the  Bath  waters,  internally  as  well  as  ex- 
ternally, is  of  service  in  the  chlorotic  state,  but  hurtful  if  the 
patient  be  of  a  full  habit.  Strict  attention  must  in  every  case  be 
paid  to  the  state  of  the  bowels.  This  is  necessary  in  the  chlorotic 
condition,  to  stimulate  the  system;  for  the  bowels  are  generally 
torpid,  and  communicate  a  similar  debility  to  the  rest  of  the  sys- 
tem. The  aloetic  or  compound  rhubarb  pill  should  be  freely  em- 
ployed.    The  cold  bath  in  chlorosis  is  seldom  proper,  as  it  is  apt 

*  There  is  much  reason  to  believe,  that  an  influence  somehow  derived  from 
the  ovaries,  excites  the  uterus  to  the  menstrual  effort. — Certain  it  is,  that  in 
several  instances,  a  permanent  suppression  of  the  menses  has  followed  the  loss 
of  these  organs.  May  not  amenorrhcra,  oftener  than  we  suspect,  be  occasioned 
by  a  diseased  state  of  the  ovaries?  This,  at  least,  was  the  opinion  of  the  cele- 
brated Cullen.  Cases  have  also  occurred,  where,  from  original  deficiency  of  the 
ovaries,  menstruation  never  took  place.    C. 


147 

to  be  followed  by  chilness,  headach,  and  languor.  It  is  only  use- 
ful when  succeeded  by  a  sense  of  heat  and  comfort.  The  warm 
salt  water  bath  is  generally  of  greater  service.  Besides  this  gene- 
ral plan,  it  has  also  been  proposed,  to  excite  more  directly  the 
uterine  action,  by  marriage,  and  the  use  of  emmenagogues ;  but 
with  respect  to  the  latter  part  of  the  proposal,  I  must  observe, 
that  some  of  these,  if  rashly,  employed,  may,  from  their  stimulat- 
ing qualities,  do  harm  ;  and  they  do  not  generally  succeed  without 
the  use  of  such  means  as  tend  to  invigorate  and  improve  the  sys- 
tem. Should  the  tonic  plan,  however,  fail,  then  we  may  employ 
some  of  those  medicines,  which  will  be  presently  mentioned. 

Chlorosis,  whether  produced  in  young  girls,  or  succeeding  to 
abortion,  laborious  parturition,  or  fever,  is  often  attended  with 
symptoms  much  resembling  phthisis  pulmonalis.  In  many  instan- 
ces the  pulse  continues  long  frequent ;  there  is  nocturnal  perspi- 
ration ;  considerable  emaciation,  with  cough  and  pains  about  the 
chest;  and  yet  the  person  is  not  phthisical,  she  suffers  chiefly  from 
debility;  but  if  great  attention  be  not  paid  to  improve  the  health, 
the  case  may  end  in  consumption ;  and  hence  many  consumptive 
women  date  the  commencement  of  their  complaints  from  an  abor- 
tion, orfrom  the  birth  of  a  child,  succeeded  by  an  hemorrhage.  In 
chlorosis,  the  symptoms  are  induced,  not  by  previous  pulmonic  af- 
fections, but  by  some  other  evident  cause  of  weakness ;  the  pulse, 
although  frequent,  is  not  liable  to  the  same  regular  exacerbation,  as 
in  hectic ;  a  full  inspiration  gives  no  pain,  and  little  excitement  to 
cough ;  the  person  can  lie  with  equal  ease  on  either  side ;  the  cough 
is  not  increased  by  motion,  nor  by  going  to  bed,  but  it  is  often 
worst  in  the  morning,  and  is  accompanied  with  a  trifling  expecto- 
ration of  phlegm.  It  is  not  short,  like  that  excited  by  tubercles, 
but  comes  in  fits,  and  is  sometimes  convulsive  ;  whilst  palpitation, 
and  many  hysterical  affections,  with  a  timid  and  desponding  mind, 
accompany  these  symptoms.  The  bowels  are  generally  costive, 
and  the  person  does  not  digest  well. 

In  chlorosis,  attended  with  symptoms  resembling  phthisis,  it  is 
of  considerable  utility,  to  administer,  occasionally,  a  gentle  emetic, 
and  at  the  same  time  the  bowels  must  be  kept  open.  Myrrh,  com- 
bined with  the  oxide  of  zinc,  is,  I  think,  of  approved  efficacy :  and 


148 

the  ammonia,  given  in  the  form  of  an  emulsion  with  oil,  very  often 
is  effectual  in  relieving  the  cough.  A  removal  to  the  country,  and 
the  use  of  moderate  exercise  on  horseback,  will  contribute  greatly 
to  the  recovery.  The  diet  ought  to  be  light  but  nourishing.  In 
many  cases  milk  agrees  well  with  the  patient,  but  it  is  not  neces- 
sary to  restrict  her  from  animal  food.  Pain  in  the  side  may  be  re- 
moved by  the  application  of  a  warm  plaster ;  and,  if  the  cough  be 
troublesome,  the  squill  may  be  used  as  an  expectorant,  and  an 
opiate  should  be  given  at  bed-time.  If  the  skin  be  permanently 
hot,  or  irregularly  hot  and  cold,  without  weakening  perspiration, 
the  tepid  bath  is  of  service,  or  small  doses  of  saline  julap  may  be 
given.  Should  the  person  be  of  a  phthisical  habit,  and  the  symp- 
toms increase  or  continue  obstinate,  it  will  be  proper  to  remove 
her  to  a  mild  climate,  or  the  southern  part  of  the  island.  Emme- 
nagogues  are  either  useless  or  detrimental. 

If  retention  should  be  combined  with  a  plethoric  state,  the  best 
plan  is  to  use  purgatives  regularly,  in  a  degree  proportioned  to 
their  effect  on  the  system,  and  make  the  patient  take  as  much  ex- 
ercise as  she  can  do  without  producing  fatigue. 

Suppression  of  the  menses  may  take  place  under  two  circum- 
stances. The  discharge  may  be  suddenly  checked  during  its  flow, 
or  it  may  be  prevented  from  taking  place  at  the  proper  period,  bjr 
the  operation  of  certain  causes  previous  to  its  expected  return. 
The  first  may  be  called  checked  menstruation,  and  it  is  produced 
chiefly  by  such  causes  as  are  capable  of  operating  powerfully  and 
speedily,  on  either  the  nervous  or  vascular  systems.  The  most 
frequent  of  these  causes  are  violent  passions  of  the  mind,  and  the 
application  of  cold  to  the  surface  of  the  body.  The  effect  is  to 
stop  the  discharge,  and  produce  great  pain  in  the  uterine  region, 
with  spasm  of  the  stomach  or  intestines,  violent  hysterical  affec- 
tions, and  not  unfrequently  smart  fever.  After  these  subside,  the 
womb  may  still  be  so  much  injured,  or  the  general  health  so  im- 
paired, that  menstruation  may  not  return  for  many  months.  The 
most  effectual  means  of  relieving  these  acute  symptoms,  are  the  se- 
micupium,  with  full  doses  of  laudanum,  combined  with  ipecacu- 
anha, or  with  the  saline  julap,  and  warm  diluents.  A  clyster  is  to 
"be  given  to  open  the  bowels,  and  this,  if  necessary,  is  to  be  sue- 


149 

ceeded  by  a  purgative.  If  there  be  febrile  symptoms,  some  blood 
should  be  taken  from  the  arm.  If  laudanum  cannot  be  retained  in 
the  stomach,  it  must  be  given  as  a  clyster,  with  some  assafoetida, 
and  the  belly  fomented  and  rubbed  with  tincture  of  soap  and  opium. 
Should  the  menses  not  return  at  the  next  period,  we  must  proceed 
as  shall  presently  be  directed. 

The  menses  may  be  prevented  from  returning  at  the  regular 
time,  by  the  interference  of  causes  during  the  interval.  This, 
which  has  been  called  obstruction,  is  naturally  produced  by  preg- 
nancy, and,  very  generally,  by  such  diseases  as  tend  greatly  to 
weaken  the  patient.  The  first  of  these  causes  is  soon  recognised, 
by  its  peculiar  effects.  In  the  second,  the  effect  is  often  mistaken 
for  the  cause ;  the  bad  health  being  attributed  to  the  absence  of 
the  menses,  and  much  harm  frequently  done  by  the  administration 
of  stimulating  medicines.  But  in  such  cases  it  will  be  found, 
upon  inquiry,  that  before  the  menses  were  suppressed,  the  patients 
had  begun  to  complain.  In  them,  the  irregularity  of  the  menses 
is  symptomatic,  and  generally  indicates  considerable  debility,  in- 
duced, perhaps,  by  great  fatigue,  bad  diet,  loss  of  blood,  or  long 
continued  serous  discharge,  hectic  fever,  or  dyspepsia.  At  the 
same  time,  it  is  also  certain,  that  in  some  instances,  the  popular 
opinion,  that  bad  health  is  produced  by  obstruction  of  the  menses, 
is  correct.  For,  if  other  organs,  as  for  instance,  the  stomach  or 
liver,  may  become  impaired  in  their  action,  and  occasion  disease, 
I  see  no  exemption  which  can  be  claimed  for  the  uterus  from  a 
similar  state,  and  this  state  unquestionably  may  influence  the  con- 
stitution. Repeated  abortion,  or  excessive  venery,  may  in  this 
way,  render  the  uterus  incapable  of  performing  its  function,  al- 
though the  general  health  may  not  for  a  length  of  time  be  injured. 
The  existence  likewise,  of  a  different  action  in  the  womb,  may  pre- 
vent menstruation ;  hence  the  effect  of  one  species  of  fluor  albus, 
that  proceeding  from  the  cavity  of  the  womb,  in  sometimes  causing 
obstruction. 

The  immediate  and  remote  effects  of  suppression,  are  much 
modified  by  the  previous  state  of  the  system,  particularly  with  re- 
gard to  irritability  and  plethora;  and  aJso  by  the  condition  of  in- 


150 

dividual  organs,*  which,  if  already  disposed  to  disease,  may  thus 
be  excited  more  speedily  into  a  morbid  action.  In  many  cases, 
nausea,  tumour  of  the  belly,  and  other  indications  of  pregnancy, 
are  produced. 

It  also  sometimes  happens,  that  in  consequence  of  suppression 
of  the  menses,  hemorrhage  takes  place  from  the  nose,  lungs,  or 
stomach ;  and  these  discharges  do  occasionally,  observe  a  monthly 
period,  but  oftener  they  appear  at  irregular  intervals.  Recorded 
instances  of  vicarious  discharges  from  almost  every  part  of  the 
body  are  so  numerous,  that  I  might  fill  a  page  with  mere  refe- 
rences. 

When  suppression  of  the  menses  takes  place  in  consequence  of 
some  chronic  and  obstinate  disease,  such  as  consumption  or  dropsy, 
it  would  be  both  useless  and  hurtful  to  attempt,  by  stimulating 
drugs,  to  restore  menstruation.  But  in  those  cases,  where  the 
menses  are  suppressed  in  consequence  of  some  removable  cause, 
which  we  conclude,  if  there  be  no  symptoms  of  other  incurable 
disease,  it  is  proper  to  interfere,  both  as  the  suppression  is  a  source 
of  anxiety  to  the  patient,  a  cause  of  farther  injury,  and  also  as  the 
rational  means  of  restoration  tend  to  amend  the  health. 

It  is  proper,  in  our  curative  plan,  to  recollect,  that  the  suppres- 
sion may  take  place  in  different  circumstances  of  the  constitution. 
It  may  occur  with  a  debilitated  condition,  in  which  case  we  are  to 
proceed  much  in  the  same  way  as  in  retention  of  the  menses, 
with  regard  to  medicine  and  diet.  Moderate  exercise,  particularly 
on  horseback,  and  a  residence  in  the  country,  will  be  of  much  ad- 
vantage, and  where  there  is  not  decided  chlorosis,  the  cold  sea 
bath  will  be  of  advantage,  provided  it  do  not  produce  headach, 
chilness,  or  languor.  In  that  case,  it  must  be  tepid.  Great  atten- 
tion must  be  paid  to  the  bowels,  and  the  digestive  powers  must, 
if  possible,  be  increased  by  steel  and  bitters,  such  as  uva  ursi, 
combined  with  soda.     Along  with  the  tonic  plan  of  treatment,  it 


*  Baillou  has  observed,  that  both  in  young  girls,  and  elderly  women,  when  the 
menses  are  obstructed  or  irregular,  the  spleen  sometimes  swells ;  and  subsides 
again  when  the  menses  become  regular.  De  Virgin,  et  Mulier.  Morbis.  Tomus 
IV.  p.  75. 


151 

will  be  proper  to  have  recourse  to  the  use  of  emmenagogue  medi- 
cines, such  as  savin,*  hellebore,f  madder,  myrrh,  mustard  seed, 
guaiac,  valerian,  or  nitrous  acid  :  and  of  these,  the  three  first  are 
the  most  active.f     About  the  time  when  the  menses  are  expected 

*  From  5  to  10  grains  of  the  powdered  leaves  may  be  given  three  or  four  times 
a  day. 

■f  A  drachm  of  the  tincture  may  be  given  twice  or  thrice  daily. 

t  In  suppression  of  the  menses,  evidently  connected  with  atony  of  the  uterus, 
I  have  had  some  success  with  the  tinct.  cantharid.  I  give  it  in  the  dose  of  ten 
drops,  morning,  noon,  and  night,  gradually  ihcreasing  the  quantity  till  it  amounts 
to  two  or  three  drachms  in  the  day.  The  most  obvious  effects  of  this  medicine, 
wliich  I  have  observed,  are  an  increase  in  the  force  of  the  pulse,  and  a  very  co- 
pious flow  of  urine. 

From  the  sp.  terebinth.  I  have  also,  under  similar  circumstances  derived  some 
advantage. 

In  one  case  of  this  complaint,  in  which  there  was  general  torpor  of  the  sys- 
tem accompanied  with  a  low  degree  of  temperature,  I  administered  phospho- 
rus, but  its  use  was  interrupted  too  soon,  by  the  prejudices  of  the  patient,  to 
judge  of  its  efficacy.  The  phosphorus  is  a  most  powerful  medicine,  and  re- 
quires great  care  in  its  administration.  I  gave  of  it,  a  tenth  of  a  grain  intimately 
blended  with  olive  oil.  Even  in  this  small  dose,  it  produced  a  universal  glow 
and  excitement.  When  properly  regulated,  phosphorus  is  both  a  safe,  and  I  be- 
lieve, an  eminently  useful  remedy.  In  the  armies  of  France,  it  has  recently  been 
employed,  I  am  told,  with  extraordinary  success  in  typhus  fever,  gangrene,  &c. 

Does  it  not  also  promise  to  do  good  in  many  other  diseases,  such  as  paralysis, 
epilepsy,  chronic  mania,  &c.  &c.    C.  (~ej 

fej  To  the  above  list  of  emmenagogue  medicines,  may  be  added  the  polygala 
senega,  first  used  in  this  complaint,  as  far  as  I  know,  by  Dr.  Hartshorne  of  this 
city,  and  introduced  to  the  notice  of  practitioners  generally,  by  Dr.  Chapman,  in 
a  paper  on  this  subject  inserted  in  the  Eclectic  Repertory  for  October,  1811 ;  in  . 
which  some  interesting  cases  and  remarks,  in  illustration  of  the  use  of  this  article 
of  the  materia  medica  are  given. 

The  mode  in  which  it  is  prepared  and  used,  is  as  follows.  In  making  the  de- 
coction, a  pint  of  boiling  water  is  added  to  an  ounce  of  the  senega,  bruised  in  a 
close  vessel ;  and  it  is  suffered  to  simmer  over  the  fire,  till  the  quantity  is  re- 
duced one-third  ;  to  prevent  nausea,  it  is  best  to  make  the  addition  of  an  aro- 
matic, such  as  the  orange  peel  or  cassia.  Four  ounces  of  this  decoction  at  a  me- 
dium, is  to  be  given  during  the  day.  But  at  the  time  when  the  menstrual 
effort  is  expected  to  be  made,  and  till  the  discharge  is  actually  induced,  the  dose 
is  to  be  pushed  as  far  as  the  stomach  will  allow.  In  the  intervals  of  the  men- 
strual periods,  the  medicine  is  directed  to  be  laid  aside  for  a  week  or  two  ;  as 
without  these  intermissions  it  becomes  nauseous  and  disgusting  to  the  patient. 
While  under  a  course  of  the  senega,  it  is  recommended  to  keep  the  general 


152 

to  appear,  it  is  sometimes  of  advantage  to  exhibit  a  mustard  eme«- 
tic,  and  to  make  use  of  the  warm  bath  or  semicupium  or  pedi- 
luvium.  Tourniquets  have,  about  this  time,  been  applied  to  the 
thighs,  but  not  with  much  benefit.  Electricity,  directed  so  as  to 
act  on  the  uterus,  is  occasionally  of  service.  Blisters  have  also 
been  applied  to  the  thighs. 

When  along  with  suppression  of  the  menses,  there  is  a  plethoric 
condition,  and  more  especially,  if  there  be  a  febrile  state,  marked 
by  heat  of  the  skin,  frequent  pulse,  flushing  pf  the  face,  and  irre- 
gular pains  in  the  chest  or  abdomen,  stimulating  medicines  are 
hurtful.  It  is,  in  this  state,  of  advantage  to  keep  the  bowels  open, 
by  the  daily  use  of  some  saline  purgative,  dissolved  in  a  conside- 
rable quantity  of  water :  and  should  there  be  dyspnoea,  with  pain 
about  the  chest,  increased  by  inspiration,  it  will  be  proper  to  take 
away  some  blood.  Should  the  skin  still  remain  hot,  the  common 
saline  julap  will  be  of  service.  The  febrile  symptoms  being  re- 
moved, much  advantage  may  be  derived  from  a  combination  of 
myrrh,  oxyde  of  iron,  and  the  supercarbonate  of  potash;  and  if 
emmenagogues  be  thought  advisable,  the  black  hellebore  is  the 
best.     The  aloetic  pill  is  the  best  purgative.* 

In  the  flabby  relaxed  habit,  in  which  there  is  a  disposition  to 
watery  effusions,  laxatives,,  squills,  and  preparations  of  steel,  with 


system  properly  regulated  ;  and  it  is  observed,  that  excessive  excitement  or  de. 
bility  is  to  be  equally  obviated  by  the  use  of  the  appropriate  remedies.  For 
fuller  information  on  this  subject  than  can  be  compressed  into  the  limits  of  a 
note,  the  reader  is  referred  to  the  interesting  paper  by  Dr.  Chapman,  above  al- 
luded to. 

*  In  chlorosis,  and,  indeed,  in  all  the  forms  of  amenorrhea,  I  have  found 
purges  very  beneficial.  Calomel  and  aloes  combined,  I  have  preferred  in  these 
cases.  To  be  useful  it  is  necessary  to  continue  this  plan  of  treatment  for  weeks. 

Professor  Hamilton,  of  Edinburgh,  who  is  a  most  skilful  practitioner  in  female 
complaints,  advises  very  strenuously,  a  mixture  of  digitalis  and  the  sp.  aether, 
nitros.  in  chlorosis.  The  former,  he  directs  in  large  doses,  as  much  as  ten  drops 
of  the  tincture  every  hour.  It  would  seem  that  digitalis  is  only  applicable  to 
those  cases  of  the  disease,  which  are  attended  with  (Edematous  swellings,  but 
he  does  not  thus  restrict  its  administration.  I  have  never  had  occasion  to  try  the 
medicine.  But  certain  it  is,  that  among  the  best  of  the  emmenagogues,  are  the 
active  diuretics,    C. 


153 

Regular  exercise,  and  frequent  friction  of  the  whole  body,  are  the 
proper  remedies  of  a  general  nature. 

§  2.  FORMATION  OF  AN  ORGANIZED  SUBSTANCE. 

It  sometimes  happens,  that  the  uterus,  instead  of  discharging  a 
fluid  every  month,  forms  a  membranous  or  organized  substance, 
which  is  expelled  with  pains  and  hemorrhage,  like  abortion.  Mor- 
gagni*  describes  this  disease  very  accurately.  The  membrane,  he 
Says,  is  triangular,  corresponding  to  the  shape  of  the  uterine  cavi- 
ty ;  the  inner  surface  is  smooth,  and  seems  as  if  it  contained  a 
fluid ;  and  that  it  does  so,  I  have  no  doubt  from  my  own  observa- 
tion ;  the  outer  surface  is  rough  and  irregular.  According  to  Mor- 
gagni,  the  expulsion  is  followed  by  lochial  discharge.^) 

Dr.  Denman  supposes,  that  no  woman  can  conceive  who  is  af- 
fected with  this  disease;  but  some  cases,  and,  amongst  others,  that 
related  by  Morgagni,  are  against  this  opinion.  Mercury,  bark, 
chalybeates,  myrrh,  and  injections,  have  all  been  tried,  but  with- 
out much  effect.  Time,  in  general,  removes  the  disease  better 
than  medicine,  which  is  only  to  be  advised  for  the  relief  of  pain> 
weakness,  or  any  other  symptom  which  may  attend  or  succeed  to 
this  state.  A  knowledge  of  this  disease  may  be  of  great  import- 
ance to  the  character  of  individuals. 

Chaussier  mentions  a  case,  where  this  membrane  presented  with. 
pain  at  the  orifice  of  the  uterus,  and  was  pulled  away  entire  with 
the  fingers.  It  was  as  large  as  a  fig,  and  filled  with  bloody  fluid. 
Collomb  describes  a  membranous  protrusion  somewhat  similar, 
which  he  conceives  to  be  a  prolapsus  or  eversion  of  the  internal 
membrane  of  the  uterus,  and  which  was  removed  by  ligature  as  a 
polypus.f 

*  Vide  Epist.  XL VIII  Art.  12. 

(f)  For  the  purpose  of  expelling  this  membrane  the  volatile  tincture  of  gum 
guiacum  has  been  recommended,  but  in  general  it  has  failed  in  affording  relief, 
as  far  as  my  experience  goes.  It  is  in  cases  of  this  description  that  the  poh  gela 
senega  had  been  particularly  recommended ;  its  use  is  theoretically  supported 
by  its  supposed  peculiar  power  in  detaching  the  membrane  of  the  croup. 

f  Diet,  des  Sciences  Medicales,  art.  Matrice. 

21 


154 


§  3.  DYSMENORRHEA. 

Some  women  menstruate  with  great  pain,  and  the  discharge 
generally  takes  place  slowly  y  and  is  sparing.  This  disease  is  called 
dysmenorrhoea.  It  seems  to  be  dependent  on  an  imperfect  men- 
strual action;  and  this  opinion  is  supported  by  observing,  that 
mild  emmenagogues  give  relief,  but  those  of  a  stimulating  quality 
are  not  so  proper.  Saffron,  madder,  or  rue,  are  often  of  service; 
at  the  same  time,  the  warm  bath,  or  semicupium,  is  to  be  employed 
for  a  day  or  two  previous  to  menstruation,  and  should  be  repeated 
every  night,  during  its  continuance.  The  bowels  are  to  be  kept 
in  a  regular  state,  by  the  careful  exhibition  of  laxatives,  and  the 
general  health  is  to  be  attended  to  on  general  principles.  During 
the  attack,  nothing  gives  so  much  relief  as  opium,  particularly  if 
combined  with  ipecacuanha,  and  given  in  a  full  dose  so  directed, 
by  tepid  diluents,  as  to  produce  perspiration.  It  is  to  be  given,  if 
possible,  just  before  the  attack.  If  it  cannot  be  kept  on  the  sto- 
mach, it  must  be  given  as  a  clyster.  The  warm  hip  bath  is  also 
of  great  benefit  during  the  paroxysm.* 

This  state  of  the  womb  sometimes  produces,  besides  uterine 
pain,  spasmodic  affection  of  the  bowels,  or  violent  bearing-down 
efforts  of  the  abdominal  muscles,  as  if  it  were  intended  to  expel 
the  womb  itself,  Such  efforts  are  also  sometimes  made  periodi- 
cally, when  the  menses  are  altogether  or  nearly  obstructed.  Un- 
der such  circumstances,  we  must  examine  carefully  into  the  state 
of  the  womb,  and  the  appearance  of  the  discharge,  or  whether 
fibrous  shreds  are  not  expelled.  If  no  organic  affection  can  be  dis- 


*  Nothing  I  have  found  to  afford  more  relief  in  painful  menstruation  than 
large  doses  of  opium  and  camphor.  This  medicine,  however,  will  often  fail.  The 
extracts  of  hyoscyamus  has  been  highly  extolled.  But  it  is  certainly  inferior  to 
opium.  It  would  be  well,  I  think,  to  try  the  datura  stramonium,  not  only  in  this, 
but  in  amenorrhcea  generally. 

Blisters,  in  those  cases,  should  not  be  omitted.  When  applied  to  the  sacrum, 
or  the  lowest  of  the  lumbar  vertebra,  they  will  sometimes  remove  the  pain  and 
bring  on  a  free  discharge  of  the  menses.  There  is,  however,  unfortunately,  in 
private  practice,  a  great  repugnance  to  the  application  of  blisters  to  these 
part$    C. 


155 

covered,  and  the  whole  appears  to  arise  from  spasm,  we  have  only 
to  trust  to  opium  in  the  meantime,  with  such  treatment  in  the  in- 
tervals, as  the  state  of  the  system  may  point  out.  Some  women 
though  they  menstruate  abundantly,  suffer  much  pain,  not  only  in 
the  uterine  region,  but  also  in  the  belly,  like  colic,  accompanied 
with  violent  vomiting  and  headach.  This  is  relieved  by  bitters, 
tincture  of  hellebore,  and  especially  laxatives  during  the  interval, 
and  by  opiates  during  the  attack  of  pain. 

§  4.  COPIOUS  MENSTRUATION. 

Some  women  menstruate  more  copiously,  or  more  frequently 
than  by  the  general  laws  of  the  female  system,  they  ought  to  do. 
The  discharge  is  menstruous,  and  does  not  coagulate,  which  dis- 
tinguishes this  state  from  uterine  hemorrhage.  Of  the  two  varie- 
ties, we  oftener  meet  with  those  who  menstruate  copiously,  and  for 
a  longer  time  than  usual,  than  with  those  who  menstruate  too  often, 
for  the  generality  of  these  do  not  menstruate,  but  have  hemorrhage. 
Copious  or  prolonged  menstruation  is  only  to  be  considered  as  a 
disease,  when  it  is  not  natural,  that  is,  when  it  has  not  been  habitual, 
and  when  it  produces  weakness.  It  may  occur  in  those  who  are 
robust  and  plethoric,  or  in  those  who  are  relaxed  and  debilitated ; 
but  women  of  the  latter  description  are  oftener  liable  to  hemorr- 
hage, than  this  state  of  menstruation.  If  it  is  necessary  to  interfere, 
we  must  enforce  that  plan  which  prevents  the  vessels  from  being 
distended  with  blood,  which  lessens  the  determination  to  the  uterus, 
and  which  rectifies  the  state  of  the  constitution  that  predisposes  to 
this  excessive  secretion.  I  need  not  be  more  particular,  as  I  shall 
enter  more  into  detail  in  the  next  section. 


§  5.  MENORRHAGIA. 

Hemorrhage  takes  place  from  the  uterine  vessels  more  frequent- 
ly than  from  any  other  organ  in  the  female  system.  It  may  occur 
in  two  very  different  states  of  the  constitution ;  in  a  full,  robust,  and 
active  habit,  or  in  a  weak  and  perhaps  emaciated  frame.   In  these 


156 

opposite  states,  the  vessels  of  the  womb  may  give  way,  in  the  oao 
case,  from  over-action,  or  distention ;  in  the  other  from  debility. 
In  the  one  there  is  generally  a  forcible  circulation,  but  always  a 
turgescence  of  the  vessels ;  in  the  other,  there  is  a  languid  motion, 
and  not  unfrequently  from  the  same  cause,  the  hemorrhoidal  ves- 
sels swell,  producing  piles.  Menorrhagia  has  therefore  been  divi- 
ded into  active  and  passive,  to  which  some  have  added  a  third  spe- 
cies, that  dependant  on  spasm. 

Uterine  hemorrhage  is  always  accompanied  with  marks  of  ute- 
rine irritation,  such  as  pain  in  the  back  and  about  the  pelvis,  and  is  be- 
sides attended  by  constitutional  or  general  symptoms,  such  as  a  fe- 
brile state  in  one  case,  and  debility,  with  hysterical  affections,  in  an- 
other. During  the  intervals  of  repeated  menorrhagia,  the  health  suf- 
fers more  or  less,  according  to  the  loss  of  blood,  and  in  addition  to  this 
general  effect,  there  is  usually,  especially  in  those  of  a  debilitated 
frame,  many  dyspeptic  affections,  and  very  often  leucorrhceal  dis- 
charge. In  process  of  time,  visceral  disease  may  be  produced,  or 
the  patient  becomes  dropsical. 

The  causes  giving  rise  to  menorrhagia,  may  be  divided  into  those 
which  occasion  the  two  predisposing  states  of  plethora,  and  weak- 
ness of  the  vascular  system,  and  those  which  act  more  immediately 
on  the  vessels  of  the  uterus.  Of  the  first  kind,  may  be  mentioned 
those  which,  on  the  one  hand,  increase  the  quantity  of  blood,  as 
rich  diet,  indolence,  &c.  and  on  the  other,  debilitate  the  body,  as 
fatigue,  abstinence,  profuse  discharges,  he.  Amongst  the  exciting 
causes,  or  those  more  particularly  affecting  the  uterine  vessels,  may- 
be mentioned,  the  excitement  produced  by  excessive  venery;  ir- 
ritation of  the  neighbouring  organs  ;  tenesmus,  worms,  torpor  of  the 
veins  produced  by  costiveness,  or  dyspepsia;  debility  of  the  womb, 
occasioned  by  abortion,  or  laborious  parturition.  Menorrhagia  may 
also  be  caused  by  irritation  of  the  vessels  communicated  by  the 
state  of  the  uterus  itself,  and  hence  it  very  often  attends  prolapsus, 
some  change  of  structure,  or  other  organic  disease,  and  therefore, 
in  all  cases  of  obstinate  discharge,  we  ought  carefully  to  examine 
the  state  of  the  womb,  both  as  to  position  and  structure. 

M arried  women  are  more  liable  to  menorrhagia  than  virgins,  and 


157 

if  is  rare  for  these,  if  otherwise  healthy,  to  have  uterine  hemorr- 
hage. 

The  management  during  the  attack,  must  depend  on  the  state 
of  the  constitution,  and  the  effect  of  the  discharge.  In  full  robust: 
habits,  when  the  pulse  is  firm,  a  febrile  state  exists,  and  the  he- 
morrhage has  not  produced  much  debility,  excellent  effects  may 
result,  as  in  other  active  hemorrhages,  from  the  early  use  of  the 
lancet,  by  which  the  uterine  discharge  is  speedily  checked,  and  that 
before  the  vessels  are  so  much  weakened  as  to  occasion  a  rapid  re- 
turn. But  if  the  pulse  be  small  or  weak,  and  no  febrile  state  exist, 
venesection  is  not  to  be  proposed,  nor  can  I  conceive,  that  it  is  in 
any  case  useful,  if  delayed  long.  Whether  the  lancet  is,  or  is  not 
to  be  used,  the  succeeding  part  of  the  treatment  is  much  the  same. 
The  patient,  on  a  general  principle,  is  to  be  kept  from  the  very  first 
in  bed,  that  she  may  be  in  a  recumbent  posture.  This  I  consider 
as  of  the  utmost  importance.  Next,  we  are  to  moderate  the  action 
of  the  vascular  system  by  cold,  that  is,  we  are  to  have  the  windows- 
open,  if  in  summer,  and  no  fire  if  winter,  and  no  more  bed-clothes 
than  are  necessary  to  prevent  shivering.  The  drink  is  to  be  spa- 
ring and  cold.  Sulphuric  acid  is  to  be  given  freely  ;  and  along 
with  this,  digitalis(7ij  may  be  prudently  administered,  so  as  to  mo- 
derate the  circulation.  For  the  same  purpose  nauseating  doses  of 
emetic  medicines  have  been  employed,  and  sometimes  with  good 
effect.  The  diet  is  to  be  almost  dry,  and  of  the  least  nutritious  qua- 
lity. Wine  and  all  stimulants  are  to  be  avoided.  In  order  to  re- 
strain the  action  of  the  uterine  vessels,  cloths  wet  with  cold  water 
are  to  be  applied  to  the  vulva,  or  to  the  back  and  pubis.  If  these 
do  not  check  the  discharge,  the  vagina  must  be  stuffed  with  a  soft 
cloth,  to  retain  the  blood  and  promote  coagulation. (i)     Acetite  of 


ChJ  Digitalis  must  be  used  with  great  caution  and  discrimination  in  uterine 
hemorrhages.  Where  it  has  been  injudiciously  exhibited,  it  has  been  known  to 
increase  the  flow  ;  particularly  where  the  inordinate  discharge  depends  upon  a 
topical  relaxation  of  the  vessels,  which  this  medicine  must  necessarily  tend  to  ag- 
gravate. 

fij  Tins  by  the  French  physicians  is  termed  le  tampon.  It  is,  perhaps,  most 
readily  effected,  by  taking  a  pretty  large  piece  of  soft  cloth,  dipping  it  in  oil,  and 


158 

lead  has  been  given  internally,  or  used  as  a  clyster,  with  good  ef- 
fect •  but  it  is  nevertheless  a  hazardous  remedy. 

In  debilitated  habits,  or  in  plethoric  patients,  when  the  discharge 
has  been  profuse,  and  produced  much  debility,  the  treatment  must 
be  modified.  Immediate  confinement  to  a  horizontal  posture,  is, 
as  in  the  former  case,  to  be  strictly  enforced.  Cold  must  be  ap- 
plied both  generally  and  locally ;  but  it  cannot  be  carried  so  far  as 
in  active  hemorrhage,  nay,  in  extreme  cases,  where  the  vital  pow- 
ers are  much  depressed,  and  the  extremities  cold,  it  may  be  ne- 
cessary to  apply  warm  flannel  to  the  feet  and  legs,  or  even  to  the 
body  in  general,  to  preserve  the  heat  requisite  for  recovery.  This 
is  a  matter  not  of  choice,  but  necessity ;  and  to  the  judgment  of 
the  practitioner  it  must  be  left,  to  avoid  the  evils  arising  from  the 
stimulating  effects  of  heat,  and  the  depressing  effects  of  cold.  In 
this,  much  attention  must  be  paid  to  the  sensations  of  the  patient. 
When  the  debility  produced  is  not  considerable,  we  are  satisfied 
with  a  horizontal  posture,  avoiding  the  stimulating  effects  of  heat, 
stuffing  the  vagina  to  promote  coagulation,  applying  cloths  wet  with 
cold  water  to  the  external  parts,  and  administering  a  dose  of  opium 
not  less  than  two  grains  ;  and  this  is  to  be  repeated  if  the  debility- 
be  greater.  I  consider  this  as  one  of  the  best  remedies  we  can 
employ,  and  when  rejected  from  the  stomach,  it  must  be  given  in 
the  form  of  clyster  or  suppository.  The  injection  of  solution  of 
sulphate  of  alumin  into  the  vagina  is  useful,  and  also  safer  than  the 
use  of  vinous  or  spirituous  injections,  which  have  been  proposed  by 
some  eminent  men.  The  diet  is  to  be  sparing,  the  drink  acidu- 
lated, and  every  exertion  avoided. 

If  the  debility  be  great,  or  the  face  pale,  the  lips  blanched,  the 
extremities  cold,  the  pulse  small,  and  the  patient  attacked  with  vo- 
miting or  syncope,  the  danger  is  not  small;  it  is  great  in  proportion 
to  the  extent  of  the  weakness,  and  the  obstinacy  of  the  discharge. 
In  such  cases  the  patient  must  be  carefully  watched.     The  vagina 


then  wringing  it  gently.  It  is  to  be  introduced  by  the  finger,  portion  after  por- 
tion, until  the  lower  part  of  the  vagina  is  well  filled.  The  remainder  is  then  to 
$.e  pressed  firmly  gn  the  orifice,  and  held  there  for  some  time. 


159 

is  to  be  kept  stuffed,  or  if  the  plug  is  removed,  it  is  only  for  the 
purpose  of  injecting  a  strong  solution  of  the  sulphate  of  alumin. 
The  strength  is  to  be  supported  by  liberal  doses  of  opium ;  by  jel- 
lies and  soups  ;  by  the  moderate  and  well-timed  use  of  wine,  either 
cold  or  warmed  with  spices  ;  by  external  heat,  so  far  as  is  neces- 
sary to  prevent  the  body  becoming  cold ;  and  by  the  use  of  aro- 
matic cordials,  such  as  aromatic  spirit  of  ammonia,  mixed  with 
cinnamon  water.  The  use  of  astringents,  if  the  stomach  can  re- 
tain them,  may  be  useful,  such  as  the  tincture  of  kino,  as  advised 
below. 

The  immediate  violence  of  the  attack,  in  either  of  the  cases  I 
have  been  considering,  being  over,  the  patient  may  remain  for 
some  time  free  from  a  return  of  the  discharge,  and  then  may  have 
another  severe  attack,  or  she  may  have  every  day  more  or  less 
hemorrhage.  I  must  therefore  next  direct  the  attention  to  those 
means  which  are  to  be  employed  for  the  permanent  cure  of  the  pa- 
tient. These  must  depend  on  the  state  of  the  constitution,  and  the 
nature  of  the  exciting  causes.  In  the  robust  or  plethoric  habit,  we> 
must  lessen  the  quantity  of  blood,  and  diminish  the  force  of  the 
circulation,  or  the  distention  of  the  uterine  vessels,  by  dry  diet,  of 
the  least  nourishing  and  stimulating  kind;  a  large  proportion  of  ve- 
getables ought  therefore  to  be  taken  at  dinner,  and  both  wine  and 
malt  liquor  should  be  avoided.  Regular  exercise  must  be  resorted 
to,  in  such  a  degree  as  shall  prevent  fulness,  and  strengthen  the 
Vessels,  on  the  one  hand,  without  going  the  length,  on  the  other,  of 
exciting  the  circulation,  so  much  as  to  produce  rupture.  Purgative 
medicines  are  of  much  service,  especially  those  which  act  also  on 
the  kidneys,  such  as  sulphate  of  magnesia,  or  Cheltenham  salts. 
These  not  only  lessen  the  quantity  of  circulating  fluids,  but  divert 
the  current  from  the  uterine  vessels.  This  may  be  farther  assisted 
by  supertartrite  of  potash,  ethereal  spirit  of  nitre,  and  other  mild 
diuretics.  As  an  exception  to  the  rule  of  employing  laxatives,  I 
must  notice  those  cases  where  hemorrhage  alternates  with,  or  seems 
excited  by,  an  irritable  state  of  the  bowels,  and  in  such  the  use  of 
opium  is  of  signal  benefit.  The  application  of  cold  to  the  surface, 
especially  if  .unequal,  and  to  the  lower  extremities,  is  hurtful,  by 


160 

determining  to  the  internal  parts.  Heat,  in  a  stimulant  view,  is  to 
be  avoided ;  but  on  the  other  hand,  cold,  by  checking  the  perspi- 
ration, is  hurtful.  The  sleep  should  be  abridged,  and  taken  on  a 
hard  bed,  with  not  too  much  covering.  The  uterine  vessels  are  to 
be  strengthened  by  the  daily  use  of  the  bidet,  and  injecting  cold 
water  into  the  vagina.  Astringent  injections  are  not  proper,  until 
the  active  state  of  the  vessels  be  removed,  after  which  they  are  of 
signal  service,  and  should  be  used  at  least  three  times  a  day. 
Every  exciting  cause  must  be  avoided.  After  the  plethoric  con- 
dition is  obviated,  the  cold  bath  is  excellent,  conjoined  with  inter- 
nal astringents. 

In  debilitated  habits,  whether  the  weakness  have  existed  from 
the  first,  or  have  succeeded  to  plethora,  the  practice  must  be  some- 
what varied.  Moderate  laxatives,  especially  mineral  waters,  are 
proper  to  improve  the  tone  of  the  bowels,  and  prevent  languid  cir- 
culation in  the  veins.  Tonic  medicines  are  to  be  given,  such  as 
different  preparations  of  iron,  chalybeate  waters,  such  as  that  of 
Tunbridge,  and  bitters;  of  the  last,  the  uva  ursi,  in  doses  of  half  a 
drachm,  three  times  a  day,  is  often  of  use ;-  at  the  same  time,  to 
either  of  these  medicines,  may  be  added  such  doses  of  squills,  as 
shall  direct  moderately  to  the  kidneys.  Some  medicines  taken  into 
the  stomach,  appear  really  to  have  the  property  of  constricting  the 
vessels  at  a  distance.  The  extract  of  rathania  root,  in  doses  of 
from  half  a  drachm  to  a  drachm,  given  two  or  three  times  a  day,  has 
been  much  extolled  by  M.  Ruitz,  but  equal,  if  not  more  certain 
benefit,  may  be  derived  from  the  exhibition  of  a  table -spoonful  of 
Tincture  of  kino  three  or  four  times  a  day.  Much  liquid  is  to  be 
avoided,  but  the  diet  should  be  more  nutritious  than  in  the  former 
case,  and  so  much  wine  may  be  given  as  shall  not  stimulate  the  cir- 
culation, or  produce  heat  or  flushing.  Claret  is  the  most  useful 
wine.  Opiates  at  bed  time  are  often  of  advantage,  in  preventing 
irritation.  The  cold  bath  is  of  great  benefit ;  and  by  way  of  pro- 
ducing contraction  of  the  uterine  vessels,  astringent  injections 
should  be  frequently  employed.  In  obstinate  cases,  a  similar  effect 
may  be  produced  by  ipecacuanha  emetics.  They  rarely  do  harm, 
and  have  been  known  to  check  the  discharge  in  very  alarming 
situations.    Friction  on  the  surface  of  the  body  is  useful,  by  deter- 


161 

mining  to  the  extreme  vessels.  Every  thing  which  can  excite  the 
uterine  vessels  must  be  avoided,  such  as  dancing,  long  walks,  ve- 
nery,  &c.  If,  in  spite  of  these  means,  the  hemorrhage  still  continue 
or  return,  there  is  reason  to  fear,  that  it  is  kept  up  by  something 
more  than  the  general  condition,  which  I  have  been  considering ; 
for  instance,  by  some  organic  affection  of  the  uterus,  not  discover- 
able by  the  ringer,  perhaps  as  yet  in  an  incipient  state ;  by  a  dis- 
eased or  varicose  state  of  the  vessels ;  or  if  the  patient  be  young, 
by  a  scrophulous  constitution,  which  does  not  readily  yield  to  ge- 
neral remedies. 

In  constant  stillicidium,  unaccompanied  with  organic  affection, 
the  best  remedies  are  tonics  and  astringent  injections.  This  often 
stops  spontaneously  for  two  days  before  and  after  menstruation. 

In  weak  habits,  there  is  sometimes  a  slight  discharge  of  blood 
for  a  day,  at  the  end  of  a  fortnight  after  menstruation.  This  is  to 
be  cured  by  strengthening  means.* 

*  Hitherto,  those  uterine  hemorrhagies  which  observe  a  periodical  regularity 
in  their  recurrence,  have  been,  very  commonly,  confounded  with  an  increased 
flow  of  the  menses.  To  this  error  we  are,  perhaps,  to  impute,  in  some  degree, 
the  uncertainty  of  our  practice  in  these  complaints.  My  own  experience  con- 
firms the  observation  of  Mr.  Burns,  "that  all  profuse  discharges  from  the  uterus 
are  hemorrhagies."  These  are  often  to  an  extent  to  threaten  immediate  clanger. 
Menorrhagia,  on  the  contrary,  even  when  most  copious,  is  never  alarming,  except 
in  its  remoter  consequences.  The  former  complaints  maybe  commonly  checked, 
like  other  hemorrhagies,  by  the  acetate  of  lead,  by  combinations  of  opium  and 
ipecacuanha,  by  bleeding  where  the  pulse  is  full  and  excited,  &.c.  But  the  latter, 
as  resulting  from  a  natural  secretory  action  of  the  uterus,  will  run  on  to  the  usual 
period  of  its  termination,  whatever  may  be  done,  unless  the  discharge  be  sup- 
pressed by  some  rash  and  violent  interference.  In  menorrhagia  proper,  little  else 
is  required  during  the  flow  than  rest,  a  cool  room,  some  acidulated  drink,  as 
cremor  tartar  :  to  open  the  bowels,  and  occasionally,  if  there  be  pain  or  irrita- 
tion, an  anodyne.  But,  in  the  intervals  of  menstruation,  we  should  endeavour  by 
various  means  to  make  such  an  impression  on  the  system  as  will  restore  to  the 
uterus  its  healthy  actions.  The  remedies,  in  these  cases,  are  well  known.  Before 
dismissing  this  subject,  it  may,  however,  be  useful  to  mention,  that  professor 
Hamilton,  of  Edinburgh,  urges  the  most  intrepid  employment  of  opium  in  peri- 
odical hemorrhagies.  He  says,  that  he  has  given,  in  a  case,  as  much  as  twelve 
grains  of  it  in  twenty -four  hours  with  singular  advantage.  Though  it  is  difficult 
with  me  to  reconcile  the  efficacy  of;  such  doses  of  opium  in  hemorrhagy  with  the 

22 


162 

CHAP.  XIV. 

Of  the   Cessation  of  the  Menses. 

About  the  period  when  the  menses  should  cease,  they  become 
irregular,  and  sometimes  are  obstructed  for  two  or  three  months, 
and  then  for  a  time  return.  This  obstruction,  like  many  other  cases 
of  retention  and  suppression  of  the  menses,  is  accompanied  with 
swelling  of  the  belly,  sickness,  and  loathing  of  food.  These  effects 
are  frequently  mistaken  for  pregnancy  :  for,  as  La  Motte  remarks, 
many  women  have  such  a  dislike  to  age,  that  they  would  rather 
persuade  themselves  they  are  with  child,  than  suppose  they  are 
feeling  any  of  the  consequences  of  growing  old ;  and  this  persua- 
sion they  indulge,  like  Harvey's  widow,  donee  tandem,  spes  omnis 
in  jiatum  et  pinguedinem  facesseret.  In  this  situation,  the  belly  is 
soft  and  equally  swelled,  and  enlarges  more  speedily  after  the  ob- 
struction, than  it  does  in  pregnancy.  No  motion  is  felt,  or  if  it  be, 
it  is  from  wind  in  the  bowels,  and  shifts  its  place.  Exercise,  cha- 
lybeates  and  laxatives,  are  the  proper  remedies  in  this  case. 

The  period  at  which  the  menses  cease,  or  "  the  time  of  life,"  is 
considered  a  critical,  and,  without  doubt,  it  is  an  important  epoch. 
If  there  be  a  tendency  to  any  organic  disease,  it  is  greatly  increased 
at  this  time,  more  especially  if  it  exist  in  the  uterus  or  mammae ; 
and,  indeed,  the  cessation  of  the  menses  does  of  itself  seem,  in 
some  cases,  to  excite  cancer  of  the  breast.  Diseases  of  the  liver, 
also,  make  greater  progress  at  this  period,  or  first  appear  soon  after 
it.  Dyspeptic  affections  are  still  more  frequent.  When  there  is 
no  tendency  to  local  disease,  it  is  very  common  for  women,  after 
the  menses  cease,  to  become  corpulent,  and  sometimes  they  enjoy 
better  health  than  formerly. 

From  an  idea  of  the  cessation  of  menstruation  being  uniformly 
dangerous,  some,  by  the  use  of  emmenagogues,  tried  to  prolong  the 

views  1  have  adopted  of  the  mode  of  operation  of  the  medicine,  yet  from  my  faith 
in  the  judgment  of  Dr.  Hamilton,  I  would,  if  necessary,  not  hesitate  to  make  the 
experiment.    C. 


163 

discharge,  others,  by  issues,  endeavoured  to  prevent  bad  effects. 
The  first  of  these  means  is  foolish  and  hurtful,  the  last  is  not  neces- 
sary. When  the  health  is  good,  no  particular  medicines  are  requi- 
site ;  but  if  there  be  a  tendency  to  any  peculiar  disease,  then  the 
appropriate  remedies  must  be  employed.  The  bowels  must  be 
kept  L^en.fk) 


CHAP.  XV. 

Of  Conception. 

Conception  seems  to  depend  upon  the  influence  of  the  semen 
exerted  on  the  ovaria,  through  the  medium  of  the  rest  of  the  geni- 
tal system ;  for  women  have  conceived,  when  semen  has  been  ap- 
plied merely  to  the  vulva,  the  hymen  being  entire. (?)  The  ovaria, 
even  in  the  virgin  state,  produce  or  form  ova,  which,  unless  semen 
be  applied,  soon  decay,  and  are  absorbed.  Sir  E.  Home*  has 
lately  called  the  attention  of  physiologists  to  this  subject,  and  main- 
tains that  corpora  lutea,  so  far  from  being  an  evidence  of  the  fe- 
male having  been  at  a  former  time  impregnated,  do  exist,  and 
come  forward  in  successive  crops,  in  the  virgin  state.  The  corpus 
luteum  is  a  mass,  according  to  him,  of  thin  convolutions,  not  unlike 
brain,  of  an  oval  shape,  with  a  central  cavity ;  and  in  some  animals, 

(fc)  For  some  interesting  practical  remarks  on  this  subject,  the  student  is  re- 
ferred to  a  paper  by  the  justly  celebrated  Dr.  J.  Fothergill,  "  on  the  manage- 
ment proper  at  the  cessation  of  the  menses,"  in  Medical  Observations  and  Inqui- 
ries, Vol.  V.     Also  in  the  Collection  of  his  Works. 

(I)  A  collection  of  cases  of  this  kind  will  be  found  in  a  work  entitled  Specula- 
tions on  Impregnation,  by  R.  Couper,  M.  D.  &c.  They  are,  however,  of  doubt- 
ful accuracy.  In  all  the  cases  of  this  kind  which  have  been  investigated  by  the 
Editor,  it  would  appear  that  minute  foramina  have  existed  in  the  membrane  call- 
ed Hymen. 

*  Phil.  Trans.  1819.  p.  59.  Blundell  controverts  this  opinion  of  Home,  in 
the  10th  Vol.  of  Med.  Chir.  Trans. 


164 

when  first  exposed,  of  a  bright  yellow  colour.  If  no  semen  be 
applied,  the  corpora,  which  are  continually  forming  during  all  the 
breeding  period  of  life,  successively  decay;  but  if  impregnation 
take  place,  the  ovum,  excited  by  the  semen,  is  carried  to  the  ute- 
rus, by  means  of  the  fallopian  tube,  which  at  the  time  embraces 
firmly  the  ovarium,  whilst  the  covering  of  the  ovum  gives  way, 
either  by  absorption  or  rupture.  Sir  E.  Home  attributes  it  to  rup- 
ture, and  says  some  blood  often  escapes  at  the  time  it  passes  down 
into  the  uterus  or  vagina.  Some  also  is  effused  into  the  cavity  of 
the  corpus  luteum,  formerly  filled  with  the  ovum.  The  coagulum 
becomes  white,  and  then  is  absorbed,  so  that  at  the  time  of  deli- 
very no  very  distinct  appearance  of  corpus  luteum  remains.  In 
some  cases  the  coagulum  is  absorbed,  and  the  cup  which  it  filled 
is  left  empty,  with  fringed  edges.  After  delivery,  distended  cor- 
pora lutea,  which  have  not  been  impregnated,  are  observable. 

Sir  E.  Home  thinks  that  the  rupture  of  the  coat  of  the  corpus 
takes  place  during  coition,  that  the  semen  may  be  directly  applied 
to  the  ovum,  but  of  this  there  is  no  proof;  whilst,  on  the  other 
hand,  there  is  incontrovertible  evidence  that  many  women  have 
conceived  when  the  semen  was  emitted  only  at  the  vulva.* 

*  Amid  the  uncertainty  which  exists  on  the  subject  of  generation,  there  seem 
to  be  some  points  very  accurately  ascertained.  Thus,  from  the  experiments  of 
De  Graaf  on  rabbits,  we  long  since  learned — 

1.  That  the  ovaries  are  the  seat  of  conception.  2.  That  one  or  more  of  their 
vesicles  become  changed.  3.  That  the  alteration  consists  in  an  enlargement  of 
them,  together  with  a  loss  of  transparency  in  their  contained  fluid,  and  a  change 
of  it  to  an  opaque  and  reddish  hue.  4.  That  the  number  of  vesicles  thus  alter- 
ed, corresponds  with  the  number  of  foetuses,  and  from  the  former  are  formed 
the  true  ova.  5.  That  these  changed  vesicles,  at  a  certain  period  after  they  have 
received  the  stimulus  of  the  male,  discharge  a  substance,  which,  being  laid  hold 
of  by  the  fimbriated  extremity  of  the  fallopian  tube,  and  conveyed  into  the  ute- 
rus, soon  assumes  a  visible  vascular  form,  and  is  called  an  ovum.  6.  That  these 
rudiments  of  the  new  animal,  which,  for  a  time,  manifested  no  arrangement  of 
patts,  afterwards  begin  to  elaborate  and  evolve  the  different  organs  of  which  the 
new  animal  is  composed.  To  these  facts  we  may  add,  that  the  calyx,  or  capsule, 
which  formed  the  pavietes  of  the  vesicles,  thickens,  by  which  the  cavity  is  dimi- 
nished. This  cavity,  together  with  the  opening  through  which  the  fatal  rudi- 
ments escaped,  becomes  obliterated,  and  from  the  parietes  of  the  vesicles  having 
acquired  a  yellowish  hue,  they  are  called  corpora  lutea.    Such  was  pretty  nearly 


165 

It  would  appear,  that  although  an  ovum  be  impregnated,  yet,  by 
various  causes,  the  process  afterwards  may  be  interrupted ;  the 
ovum  Shrivels  and  is  absorbed.  If  there  be  an  impervious  state 
of  the  tubes,  or  any  conformation  or  condition,  rendering  it  im- 
possible for  a  child  to  be  supported,  the  ovum  decays,  and  the 
woman  is  barren.  Or  if  such  a  state  be  induced  after  impregna- 
tion, and  before  the  ovum  descends,  the  process  stops.* 

In  the  human  subject,  only  one  ovum  is  generally  impregnated 
by  one  seminal  application,  but  sometimes  two  or  more  may  be 

the  extent  of  our  information  respecting  this  mysterious  function,  when  the  cele- 
brated Mr.  Haighton  some  few  years  ago  engaged  in  an  experimental  investiga- 
tion of  the  subject,  and  established,  among  others,  the  following  additional 
points. 

1.  That  the  existence  of  the  corpora  lutea,  as  was  previously  alleged  by  De 
Graaf,  is  incontestible  proof  of  impregnation  having  preceded. 

2.  That  contrary  to  the  opinions  of  most  physiologists,  neither  the  vesicle  of 
the  ovary  is  ruptured,  nor  the  fallopian  tube  applied  to  the  ovary  during  the  act 
of  coition ;  but,  that  several  daj  s  elapse  before  the  vesicle  arrives  at  sufficient 
maturity  to  discharge  its  contents,  till  which  time,  the  fallopian  tube  does  not 
change  its  ordinary  position. 

3.  That,  in  contradiction  to  the  observation  of  De  Graaf,  Malpighi,  and  Cruik- 
shank,  the  substance  which  passes  from  the  ovary  is  merely  a  gelatinous  fluid, 
which  assumes  nothing  of  the  circumscribed  vesicular  character  of  the  ovum  till 
a  considerable  period  after  it  is  deposited  in  the  uterus. 

4.  That  the  semen  masculinum  is  applied  to  the  ovary  neither  by  the  fallopian 
tubes,  nor  by  absorption,  nor  in  the  form  of  aura  seminalis. 

He  concludes,  therefore,  that  fecundation  is  performed  by  that  "  law  of  the 
animal  system  termed  sympathy,  or  consent  of  parts."  The  doctrine  is  thus 
stated : 

The  semen  first  stimulates  the  vagina,  os  uteri,  cavity  of  the  uterus,  or  all  of 
them. 

By  sympathy  the  ovarian  vesicles  enlarge,  project,  and  burst. 

By  sympathy  the  tubes  incline  to  the  ovaries,  and  having  embraced  them,  ccfTi. 
vey  the  rudiments  of  the  foetus  to  the  uterus. 

By  sympathy  the  uterus  makes  the  necessary  preparations  for  perfecting  the 
formation  and  growth  of  the  foetus:  and,  finally, 

By  sympathy  the  breasts  furnish  milk  for  its  support  after  birth.    C. 

*  Dr.  Haighton  found,  that  by  dividing  the  tubes  after  a  rabbit  was  impregi 
nated,  the  ova  were  destroyed.  Or  if  only  one  tube  was  cut,  and  the  female  af- 
terwards became  impregnated,  corpora  lutea  were  found  in  both  ovaria,  but  no 
ova  were  found  in  the  tube  or  horn  of  the  uterus,  on  the  injured  side.  Phil. 
Trans.  Vol.  I  .XXXVII.  p.  175,  &c 


166 

carried  down  into  the  uterus,  and  even  after  one  ovum  has  reached 
the  uterus,  and  grown  to  a  certain  degree  within  it,  we  find,  that 
it  is  possible  for  a  second  to  be  excited  into  action,  and  brought 
down  into  the  womb,  where  it  is  nourished  and  supported.* 

Mr.  Hunterf  supposed  that  each  ovarium  is  capable  of  produc- 
ing only  a  certain  number  of  ova ;  and  that  if  one  ovarium  be  re- 
moved or  rendered  useless,  the  constitution  cannot  give  to  the 
other  the  power  of  producing  as  many  ova  as  could  have  been 
done  by  both. 

It  has  been  attempted  to  ascertain  what  age,  and  what  season 
was  most  prolific.  From  an  accurate  register  made  by  Dr.  Bland, 
it  would  appear,  that  more  women,  between  the  age  of  twenty-six 
and  thirty  years,  bear  children,  than  at  any  other  period.  Of  2102 
women,  who  bore  children,  85  were  from  fifteen  to  twenty  years 
of  age ;  578  from  twenty-one  to  twenty-five  ;  699  from  twenty-six 
to  thirty;  407  from  thirty-one  to  thirty-five;  291  from  thirty-six 
to  forty;  36  from  forty-one  to  forty-five;  and  6  from  forty-six  to 
forty-nine. 

At  Marseilles,  M.  Raymond  says,  women  conceive  most  readily 
in  autumn,  and  chiefly  in  October ;  next  in  summer,  and  lastly  in 
winter  and  spring  ;  the  month  of  March  having  fewest  conceptions. 
M.  Morand  again  says,  that  July,  May,  June,  and  August,  are  the 
most  frequent  dates  of  conception  ;  and  November,  March,  April. 
and  October,  the  least  frequent  in  the  order  in  which  they  are  enu- 
merated. I  have  been  favoured  with  a  register,  for  ten  years,  of 
an  extensive  parish  in  this  place  ;  from  which  it  appears,  that  the 
greatest  number,  both  of  marriages  and  births,  take  place  in  May, 
and  the  fewest  births  in  October.  From  this  we  would  consider 
August  and  September  to  be  most  favourable  to  conception  ;  but 
it  is  evident,  that  these  conclusions  are  liable  to  great  uncertainty. 

Women  are  supposed  to  conceive  most  readily  immediately  af- 
ter the  menstrual  evacuation,  but  it  is  doubtful  how  far  this  opinion 
is  correct ;  and  therefore,  in  calculating  the  time  when  labour 
should  be  expected,  it  is  usual  to  count  from  a  fortnight  after  the 

*  Vide  Med.  and  Phys.  Journ.  Vol.  XVII.  p.  489. 
7  Vide  Phil.  Trans.  Vol.  LXXV1I. 


167 

last  appearance  of  the  menses,  or  to  say  that  the  woman  would  be 
confined  at  the  end  of  the  forty-second  week  from  that  period. 

The  process  of  gestation  usually  requires  forty  weeks,  or  nine 
calender  months  for  its  completion ;  but  many  circumstances  may 
render  labour  somewhat  premature,  and  it  is  even  possible  for  the 
process  to  be  completed,  and  the  child  perfected  to  its  usual  size,  a 
week  or  two  sooner  than  the  end  of  the  ninth  month.  On  the 
other  hand,  it  is  equally  certain  that  some  causes,  which  we  can- 
not explain  nor  discover,  have  the  power  of  retarding  the  process, 
the  woman  carrying  the  child  longer  than  nine  months  ;(m)  and 
the  child,  when  born,  being  not  larger  than  the  average  size.  How 
long  it  is  possible  for  labour  to  be  delayed  beyond  the  usual  time, 
cannot  easily  be  ascertained  ;  but  it  is  very  seldom  protracted  be- 
yond a  few  days,  counting  the  commencement  of  pregnancy  from 
the  day  preceding  that  on  which  the  menses  ought  to  have  appear- 
ed, had  the  woman  not  conceived. 


CHAP.  XVI. 

Of  the  Gravid  Uterus. 
§  1.  SIZE  AND  POSITION. 

When  we  compare  the  unimpregnated  with  the  gravid  uterus  at 
the  full  time,  we  must  be  astonished  at  the  change  which  has  taken 
place  during  gestation,  in  its  magnitude  alone. 

fmj  The  ancient  laws  of  France  allowed  that  a  legitimate  birth  might  take 
place  ten  months  after  the  connexion  of  the  sexes  :  in  Scotland,  the  law  consi- 
ders a  child  born  six  months  after  the  marriage  of  the  mother,  or  ten  months  af- 
ter the  death  of  the  father,  as  legitimate.  The  English  law,  which  has  been 
adopted  in  the  United  States,  considers  all  children  as  legitimate,  who  are  bom 
m  lawful  matrimony,  or  within  about  forty  weeks  after  the  dissolution  of  the 
marriage  by  the  death  of  the  husband.  It  endeavours  to  avoid  enquiring  when, 
or  by  whom  the  child  may  have  been  begotten  ;  the  general  rule  being  presumi 
fur  pro  legitimations. 


168 

Jn  the  ninth  month  the  size  of  the  womb  is  so  much  increased, 
that  it  extends  almost  to  the  ensiform  cartilage  of  the  sternum  ;  and 
this  augmentation  it  receives  gradually,  but  not  equally,  in  given 
times;  for  it  is  found  to  enlarge  much  faster  in  the  latter,  than  in 
die  earlier  months  of  pregnancy.  This  is  true,  however,  only  with 
regard  to  the  absolute  increase,  for  in  the  first  month,  the  uterus 
perhaps  doubles  its  original  size,  but  it  does  not  go  on  in  the  same 
ratio.     It  is  not  twice  as  large  in  the  ninth  as  in  the  eighth  month. 

In  the  second  month  the  uterus  is  enlarged  in  every  part  without 
much  change  of  shape.  Towards  the  end  of  the  third  month,  it 
generally  measures  from  the  mouth  to  the  fundus  above  five  inches, 
one  of  which  belongs  to  the  cervix.  In  the  fourth  month,  it  reaches 
a  little  higher,  and  measures  five  inches  from  the  fundus  to  the  be- 
ginning of  the  neck.  In  the  fifth,  it  has  become  so  much  larger,  as 
to  render  the  belly  tense,  and  may  be  felt,  like  a  ball,  extending  to 
a  middle  point  between  the  pubis  and  the  navel,  and  measures 
about  six  inches  from  the  cervix  to  the  fundus.  In  other  two  months, 
it  reaches  to  the  navel,  and  measures  about  eight  inches.  In  the 
eighth  month,  it  ascends  still  higher,  reaching  to  about  half  way 
between  the  navel  and  the  sternum.  In  the  ninth  month,  it  reach- 
es almost  to  the  extremity  of  that  bone,  at  least  in  a  first  pregnancy, 
when  the  tightness  of  the  integuments  prevents  it  from  hanging  so 
much  forward  as  it  afterwards  does.  At  this  time,  it  generally  mea- 
sures, from  top  to  bottom,  ten  or  twelve  inches,  and  is  oviform  in 
its  shape.  For  the  first  month,  the  shape  of  the  uterus  is  not  al- 
tered ;  it  is  enlarged  in  every  direction.  But  after  this,  it  swells 
before  and  behind,  and  soon  becomes  globular,  having  the  cylin- 
drical undistended  cervix  depending  from  it;  after  the  fifth  month 
it  becomes  more  oblong,  and  by  the  seventh,  it  resembles  a  balloon. 
These  calculations  are  not  invariably  exact,  suiting  every  case, 
but  admit  of  modifications. 

In  pregnancy,  the  mouth  of  the  uterus  is  directed  backward, 
whilst  the  fundus  lies  forward.  This  obliquity,  however,  does 
not  take  place  until  the  uterus  begins  to  rise  out  of  the  pelvis,  and 
it  always  exists  in  a  greater  degree  in  those  who  have  born  many 
children. 


169 

From  this  position  it  appears,  that  the  intestines  can  never  be 
before  the  uterus,  but  must  lie  behind  it  and  round  its  sides. 

Previous  to  the  descent  of  the  ovum,  the  uterus  begins  to  en- 
large especially  at  its  upper  part,  or  fundus ;  and  it  is  worthy  of 
notice,  that  the  posterior  face  of  the  uterus  always  distends  more 
than  the  anterior  one,  as  we  ascertain  by  examining  the  situation 
of  the  orifices  of  the  fallopian  tubes. 

When  the  fundus  begins  to  increase,  it  not  only  grows  heavier, 
but  also  presents  a  greater  surface  for  pressure  to  the  intestines 
above  :  it,  therefore,  will  naturally  descend  lower  in  the  pelvis, 
and  thus  project  farther  into  the  vagina.  In  this  situation  the  ute- 
rus will  remain,  until  it  become  so  large  as  to  rise  out  of  the  pel- 
vis. This  ascent  takes  place  generally  about  the  sixteenth  week 
of  pregnancy,  if  the  pelvis  be  well  formed,  and  the  uterus  increase 
in  the  usual  ratio. 

§  2.  DEVELOPMENT  OF  THE  UTERUS,  8cc. 

In  the  fifth  month  of  pregnancy,  the  cervix  begins  to  be  de- 
veloped :  so  that  by  the  end  of  the  month,  one  quarter  of  its  length 
has  become  distended,  and  contributed  to  augment  the  uterine 
cavity ;  the  other  three-fourths,  which  remain  projecting,  become 
considerably  softer,  rather  thicker,  and  more  spongy.  In  another 
month,  one  half  of  the  cervix  is  distended,  and  the  rest  is  still 
more  thickened,  or  the  circumference  of  the  projecting  part  greater: 
the  uterus  has  also  risen  farther  up,  and  the  vagina  is  more  elon- 
gated. In  the  seventh,  we  may,  with  the  finger,  distinguish  the 
head  of  the  child  pressing  on  the  lower  part  of  the  uterus,  which 
we  can  seldom  do  before  this.  In  the  eighth  month,  the  neck  is 
completely  effaced,  and  its  orifice  is  as  high  as  the  brim  of  the 
pelvis.  The  ninth  month  affects  the  mouth  of  the  uterus  chiefly. 
The  alterations  of  the  cervix  are  discovered,  by  introducing  the 
finger  into  the  vagina,  and  estimating  the  distance  betwixt  the  os 
uteri  and  the  body  of  the  uterus,  which  we  feel  expanding  like  a 
balloon. 

The  mouth  of  the  uterus  is  merely  the  termination  or  extremity 
of  the  cervix,  and  consists  of  two  lips  of  the  same  consistenr-e  with 

J.) 


170 

the  rest  of  the  uterus.  When  the  womb  is  not  gravid,  these  arc 
always  open,  and  will  admit  the  tip  of  the  finger.  But,  soon  after 
conception,  the  os  uteri  becomes  closer,  softer,  and  rather  circular 
than  transverse.  In  proportion  as  pregnancy  advances,  and  the 
cervix  stretches,  the  lips  shorten,  until  they  sometimes  totally  dis- 
appear ;  but  more  frequently  they  continue  to  project  a  little,  un- 
til labour  commences.  All  the  inner  surface  of  the  cervix  uteri, 
in  the  whole  course  of  gestation,  is  full  of  glandular  follicles,  which 
secrete  a  thick  viscid  mucus.  This  extends  from  the  one  side  to 
the  other,  and  fills  up  the  mouth  of  the  uterus  very  perfectly,  being 
thus  interposed  as  a  guard  betwixt  the  membranes  and  any  foreign 
body.  By  maceration,  it  may  be  extracted  entire,  when  a  mould 
of  the  lacunae  will  be  obtained  by  floating  it  in  spirits,  saturated 
with  fine  sugar. 

§  3.  MUSCULAR  FIBRES. 

Vesalius  describes  three  strata  of  muscular  fibres,  transverse, 
perpendicular,  and  oblique.  Malpighi  describes  them  as  forming 
a  kind  of  net  work  ;  whilst  Ruysch  maintains,  that  they  appear  at 
the  fundus,  in  concentric  planes,  forming  an  orbicular  muscle.  Dr. 
Hunter  paints  them  as  transverse  in  the  body  of  the  uterus,  but,  at 
the  fundus  describing  concentric  circles  around  each  of  the  fallo- 
pian tubes.  These  contradictions  of  anatomists  serve  to  show, 
what  may  readily  be  seen  by  examining  the  uterus,  that  the  fibres 
are  not  very  regular  and  distinct  in  their  course,  but  exhibit  con- 
fusion, rather  than  any  well  marked  figure. 

The  increased  size  of  the  uterus  is  by  no  means  chiefly  owing 
to  the  addition  of  muscular  fibres.  These  become  indeed  larger, 
and  better  developed,  but  do  not  contribute  so  much  to  the  in- 
crease, as  the  enlargement  of  the  blood  vessels,  and  perhaps  the 
deposition  of  cellular  substance.  This  gives  the  uterus  a  very- 
spongy  texture,  and  makes  it  so  ductile,  that  a  small  aperture  may 
be  greatly  dilated,  without  tearing.  From  examination,  it  appears, 
that  although  the  whole  uterus  does  not  grow  thinner  in  proportion 
to  its  increase,  yet  it  does,  at  the  full  time,  become  thinner  near 


171 

the  mouth  ;  whilst  the  fundus  continues  the  same,  or  perhaps  grows 
a  little  thicker,  at  least  where  the  placenta  i6  attached. 

§  4.  LIGAMENTS. 

No  one,  who  understands  the  anatomy  of  the  ligaments  of  the 
unimpregnated  uterus,  will  be  surprised  to  find  a  great  change  pro- 
duced in  their  situation  and  direction,  by  pregnancy.  The  broad 
ligament,  which  is  only  an  extension  of  the  peritoneum  from  the 
sides  of  the  uterus,  is,  in  the  ninth  month,  by  the  increase  of  the 
viscus,  spread  completely  over  its  surface  ;  and  consequently,  were 
we  to  search  for  this  ligament,  we  would  be  disappointed.  Its  du- 
plicatures  are  all  separated  and  laid  smoothly  over  the  uterus.  It 
will  therefore  be  evident,  that  we  can  no  longer  find  the  ovaria  and 
fallopian  tubes  floating  loose  in  the  pelvis,  nor  the  round  ligaments 
running  out  at  an  angle  from  the  fundus  uteri  to  the  groin.  All 
these  are  contained  within  duplicatures  of  the  peritoneum,  or  liga- 
mentum  latum  ;  and  therefore,  when  this  is  spread  over  the  uterus, 
it  follows,  that  the  ovaria,  tubes,  and  round  ligaments,  cannot  now- 
run  out  loosely  from  the  uterus,  but  must  be  laid  flatter  on  its  sur- 
face, and  bound  more  by  the  stretched  peritoneum.  This  descrip- 
tion applies  only  to  the  state  of  the  uterus  at  the  full  time.  Ear- 
lier, we  may  readily  observe  the  broad  ligament  flying  out,  and  al- 
lowing the  ovaria  free  play.  The  loose  extremity  of  the  tube  be- 
comes more  expanded,  and  very  vascular,  and  forms  a  kind  of 
cavity  called  the  antrum. 

On  the  ovarium  we  observe  a  corpus  luteum.  This  is  a  sub- 
stance once  described  as  divisible  into  cortical  and  medullary  mat- 
ter, placed  immediately  under  the  membrane  of  the  ovarium,  and 
adhering  to  the  ovarium  by  cellular  substance.  It  is  of  a  yellow- 
ish colour,  and  is  largest  soon  after  conception.  The  nature  of 
this  has  already  been  described. 

§  5.  VESSELS. 

The  origin  and  distribution  of  the  blood  vessels  of  the  uterus 


172 

have  been  formerly  noticed  ;  I  have  only  to  add,  that,  in  pregnan- 
cy, they  become  prodigiously  enlarged.  Even  before  the  ovum  is 
very  visible,  we  find  the  uterine  artery  as  large  as  the  barrel  of  a 
goose  quill,  and  sending  large  branches  round  the  cervix  uteri, 
and  up  the  sides  of  the  womb.  As  pregnancy  advances,  the 
trunks,  but  especially  the  branches,  become  still  larger,  particular- 
ly near  the  implantation  of  the  placenta.  The  veins  are  enlarged 
in  the  same  proportion  with  the  arteries.  They  are  destitute  of 
valves,  and  receive  the  name  of  sinuses. 

The  lymphatics  are  very  large  and  very  numerous.  The  nerves 
have  already  been  described. 

§  6.  OF  THE  FCETUS. 

Although  many  opportunities  have  occurred  to  anatomists,  of  ex- 
amining not  only  abortions,  but  also  the  uterus  itself,  at  an  early  pe- 
riod of  gestation  ;  yet  it  has  not  been  exactly  determined  at  what 
precise  time  the  ovum  enters  the  womb,  or  when  the  foetus  first  be- 
comes visible.  This  may  depend,  partly  on  want  of  information 
respecting  the  exact  number  of  days  which  have  intervened  betwixt 
impregnation  and  our  examination  ;  and  partly,  perhaps,  upon  ir- 
regularitieb  of  the  process  in  the  human  female,  induced  by  various 
causes. 

We  know  that  considerable  changes  take  place  in  the  cavity  of  the 
uterus,  before  the  ovum  descends ;  but  the  time  required  for  the  ac- 
complishment of  these  is  not  determined.  In  a  very  accurate  dissec- 
tion performed  by  the  late  Mr.  Hunter,  and  related  by  Mr.  Ogle,* 
no  ovum  could  be  found  either  in  the  uterus  or  the  tubes,  although 
there  is  reason  to  suppose  that  nearly  a  month  had  elapsed  from  the 
time  of  impregnation.  I  have  examined  very  carefully  three  uteri 
within  the  first  month,  and  have  not  been  able  to  discover  either  ovum 
or  foetus.  If  we  admit  analogical  evidence  on  this  subject,  we  shall  be 
more  confirmed  in  a  belief  that  the  ovum  does  not,  in  the  human  fe- 
male, enter  the  uterus,  until  at  least  three  weeks  after  conception.! 

*  Transactions  ofa  Society,  &.c.  Vol.  II.  Art.  vi. 

f  Dr.  Combe  possessed  a  preparation,  where  tbere  was  an  appearance  ofa  very 


173 

In  the  rabbit,  whose  period  of  gestation  is  only  thirty  days,  the  ovum 
is  not  to  be  found  in  the  uterus  earlier  than  the  fourth  day,  accord- 
ing to  Mr.  Cruikshanks,*  or  the  sixth,  according  to  Dr.  Haighton  ; 
and  the  foetus  is  not  visible  till  the  eighth  day,  when  it  maybe  seen 
by  dropping  vinegar  on  the  ovum.f  Haller  found,  that,  in  the  sheep, 
whose  term  of  gestation  is  five  months,  the  ovum  does  not  enter 
the  uterus  till  the  seventeenth  day,f  and  the  foetus  is  not  visible  till 
the  nineteenth.  These  observations  and  conclusions  would  appear 
to  be  overturned  by  a  recent  observation  of  Sir  E.  Home,^  who, 
after  soaking  the  uterus  in  spirits,  detected  an  ovum  within  it,  when 
he  supposed  that  only  eight  days  had  intervened  between  impreg- 
nation and  death.  The  cavity  of  the  uterus  was  lined  with  deci- 
dua ;  and  the  plate  corresponds  most  exactly  to  the  appearance  I 
have  seen  in  three  different  cases  I  have  just  alluded  to,  and  where 
I  believe  the  period  to  be  more  advanced.  In  these,  I  could  detect 
no  ovum  ;  but  Sir  E.  Home,  by  the  use  of  spirits,  rendered  it  more 
distinct,  and  found  it  entangled  in  the  fibres  of  the  decidua,  near 
the  cervix  uteri.  It  had  an  oval  shape  ;  one  part  was  quite  white, 
the  other  transparent ;  but,  soon  after,  being  exposed  to  the  spirits, 
the  white  became  opaque.  Mr.  Bauer  examined  it  by  the  micros- 
cope, and  found  it  to  resemble  very  much  a  little  shell  of  the  ge- 
nus voluta,  the  membrane  being  open,  like  a  shell,  along  one  side; 
another  smaller  membrane  seemed  to  be  contained  within,  filled 
with  a  thick  slimy  substance,  and  enveloping  two  small  cor- 
puscles of  a  yellowish  tint,  supposed  to  be  the  brain  and  heart.  The 
inner  membrane  formed  an  oval  ^  of  an  inch  long,  and  not  quite 
3§ r  broad.  The  whole  ovum  was  ^  long,  and  5f  T  broad ;  that 
is,  it  was  nearly  about  the  size  of  a  canary  seed.  The  os  uteri  was 
shut  up  with  solid  jelly. 


minute  foetus.  From  peculiar  circumstances,  two  and  twenty  clays  were  suppo- 
sed to  have  elapsed  from  the  time  of  conception.  Vide  Dr.  Hunter's  Anatorp. 
Descrip.  p.  87. 

*  Phil.  Trans.  Vol.  LXXXVII. 

-j  Phil.  Trans.  Vol.  LXXXVII.  p.  204. 

t  Elementa,  Tom.  VIII.  p.  59.— Opera  Minora,  Tom.  II.  p.  434. 

§  Phil.  Trans.  1817.  Part  2d, 


174 

The  ovum,  at  first,  contains  no  embryo  visible  to  the  naked  eye; 
nothing  but  vesicular  involucra  appear.  This  point  is  fully  estab- 
lished by  examining  the  inferior  animals,  and  is  especially  confirm- 
ed by  the  incubation  of  the  eggs  of  fowls.  I  have  examined  care- 
fully a  most  perfect  ovum  in  the  ninth  week  after  menstruation, 
consequently  not  less  than  the  fifth  after  conception.  In  it  no  dis- 
tinctly organized  embryo  could  be  detected.  The  chorion  was  as 
large  as  a  small  chesnut,  covered  with  shaggy  vessels,  and  filled 
with  transparent  jelly,  like  the  vitreous  humour  of  the  eye.  With- 
in, and  adhering  to  one  side,  was  the  amnion,  not  much  larger  than 
a  coriander  seed.  It  contained  nothing  but  transparent  fluid  ;  but 
I  did  not  try  the  effect  of  rendering  the  contents  opaque  by  spirits. 

When  the  human  foetus  is  first  distinctly  visible  through  the  mem- 
branes,'it  is  not  above  a  line  in  length,  and  of  an  oblong  figure. 
In  the  sixth  week,  it  is  seen  slightly  curved,  resembling  as  it  floats 
in  the  water,  a  split  pea.  In  the  seventh  week,  it  is  equal  in  size 
to  a  small  bee  ;  and,  by  the  conclusion  of  the  second  month,  it  is 
bent,  and  as  long  as  a  kidney  bean. 

The  embryo,  at  first,  appears  to  the  naked  eye  like  two  oval 
bodies  of  unequal  size,  united  together  by  a  neck.  The  one  of 
these  is  the  head,  the  other  the  trunk.  The  head  is  a  membranous 
bag,  which  is  large  in  proportion  to  the  body ;  but  after  the  first 
month  of  its  growth,  the  relative  size  decreases :  on  opening  it, 
nothing  but  a  soft  pulp  is  found  within.  In  a  little  time,  the  face 
appears,  the  most  prominent  features  of  which  are  the  eyes ;  these 
are  proportionally  larger  in  the  embryo  than  in  the  advanced  foetus, 
and  are  placed  low  down.  The  face  itself  is  small,  compared  to 
the  cranium.  The  nose  does  not  appear  until  the  end  of  the 
second,  month,  but  somewhat  sooner,  we  may  observe  two  aper- 
tures in  the  situation  of  the  nostrils.  The  mouth,  at  first,  is  a 
round  hole,  but  by  degrees  lips  appear ;  and  after  the  third  month, 
they  are  closed,  but  do  not  cohere.  The  external  ear  is  not  form- 
ed at  once,  but  in  parts,  and  is  not  completed  before  the  fifth 
month ;  even  then,  it  differs  in  its  shape  from  the  ear  after  birth. 
It  is  at  first  like  a  gently  depressed  circle. 

The  extremities  early  appear  like  the  buds  of  a  plant.  The 
arms  are  directed  obliquely  forward,  toward  the  face,  and  are  lar-. 


175 

ger  than  the  inferior  extremities.  The  genitals,  for  a  time,  are 
scarcely  to  be  observed  ;  but  in  the  third  month,  they  are  large  in 
proportion  to  the  body. 

The  foetus  does  not  grow  in  a  uniform  ratio,  but,  as  has  been 
observed  by  the  learned  anatomist,  Dr.  Soemmering,^  the  in- 
crement is  quicker  in  the  third  than  in  the  second  month.  In  the 
beginning  of  the  fourth  it  becomes  slower,  and  continues  so  until 
the  middle  of  that  month,  when  it  is  again  accelerated.  In  the 
sixth  month,  it  is  once  more  retarded,  and  the  progression  re- 
mains slow  during  the  rest  of  gestation. 

The  proportion  between  the  weight  of  the  fetus  and  its  involu- 
cra,  is  reversed  at  the  beginning  and  the  end  of  gestation.  When 
the  embryo  does  not  weigh  more  than  a  scruple,  the  membranes 
are  as  large  as  a  small  egg.  Even  when  the  foetus  is  not  larger 
than  a  fly,  the  membranes  resemble,  in  shape  and  size,  a  large 
chesnut.  On  the  other  hand,  at  the  full  time,  when  the  foetus 
weighs  seven  pounds,  the  placenta  and  membranes  do  not  weigh 
a  pound  and  a  half,  and  the  proportion  of  liquor  amnii  is  greatly 
lessened.  In  the  twelfth  week,  the  foetus  weighs  nearly  two 
ounces,  and  measures,  when  stretched  out,  about  three  inches. 
The  membranes  are  larger  than  a  goose's  egg,  and  weigh,  if  we 
include  the  liquor  amnii,  several  ounces.  In  the  fourth  month, 
the  foetus  is  about  five  inches  long.  In  the  fifth  month,  it  measures 
six  or  seven  inches.  In  the  sixth  month,  the  foetus  is  perfect  and 
well  formed,  measures  eight  or  nine  inches,  and  weighs  about  one 
pound  troy  ;  whilst  the  placenta  and  membranes  weigh  about  half 
a  pound,  exclusive  of  the  liquor  amnii.  The  foetus  is  now  so  vigo- 
rous in  its  action,  that  there  have  been  instances,  though  most  rare, 
of  its  continuing  to  live,  if  born  at  so  premature  a  period.     In  the 

(~oJ  The  student  is  particularly  requested,  where  that  most  valuable  work  is 
within  his  reach,  to  compare  this  description  of  the  fetus  in  its  different  stages 
of  progressive  development  and  growth,  with  the  most  accurate  and  elegant 
plates  of  Soemmering,  entitled,  Icones  Embryonum  Humanorum.  Dr.  Hunter's 
plates  of  the  gravid  uterus,  are  also  highly  worthy  of  inspection.  These  invalu- 
able works  may  be  almost  said  to  supply  the  place  of  anatomical  preparations ; 
so  closely  and  minutely  has  nature  been  copied  by  the  faithful  pencil  and  grai 
of  the  artist. 


176 

seventh  month,  it  has  gained  about  three  inches  in  length,  and  is 
now  more  able  to  live  independent  of  the  uterus ;  though  even  at 
this  time,  the  chance  of  its  surviving  six  hours  from  birth  is  much 
against  it.  In  the  eighth  month,  it  measures  about  fifteen  inches, 
and  weighs  four,  or  sometimes  five  pounds,  whilst  the  involucra 
weighs  scarcely  one.  These  calculations  vary  according  to  the 
sex  of  the  child,  and  also  the  conformation  of  the  parents.  Male 
children  generally  weigh  more  than  females.  Dr.  Roederer*  con- 
cludes, from  his  examinations,  that  the  average  length  of  a  male, 
at  the  full  time,  is  twenty  inches  and  a  third  ;  whilst  that  of  a  fe- 
male is  nineteen  inches  and  seventeen  eighteenths.  Dr.  Joseph 
Clarke  has  given  a  table  of  the  comparative  weight  of  male  and 
female  children  at  the  full  time,  from  which  it  appears,  that  although 
the  greatest  proportion  of  both  sexes  weigh  seven  pounds,  yet 
there  are  more  females  than  males  found  below,  and  more  males 
than  females  above,  that  standard.  Thus,  whilst  out  of  sixty  males, 
and  sixty  females,  thirty-two  of  the  former,  and  twenty-five  of  the 
latter,  weighed  seven  pounds ;  there  were  fourteen  females,  but 
only  six  males,  who  weighed  six  pounds.  On  the  other  hand, 
there  were  sixteen  males,  but  only  eight  females,  who  weighed 
eight  pounds.  Taking  the  average  weight  of  both  sexes,  it  will  be 
found,  that  twelve  males  are  as  heavy  as  thirteen  females.  The 
placenta  of  a  male  weighs,  at  an  average,  one  pound  two  ounces 
and  a  half,  whilst  that  of  a  female  weighs  half  an  ounce  less.  Fe- 
male children,  who,  at  the  full  time,  weigh  under  five  pounds,  rare- 
ly live ;  and  few  males,  who  even  weigh  five  pounds,  thrive. 
They  are  generally  feeble  in  their  actions,  and  die  in  a  short  time. 
When  there  are  two  children  in  utero,  the  weight  of  each  indi- 
vidual is  generally  less  than  that  of  the  foetus  who  has  no  compa- 
nion ;  but  their  united  weight  is  greater.  When  a  woman  has 
twins,  it  either  usually  happens,  that  both  children  are  small,  or 
one  is  of  a  moderate  size,  and  the  other  is  diminutive ;  though  I 
have  known  instances,  where  both  the  children  were  rather  above, 
than  under  the  usual  standard.  The  average  weight  of  twelve 
ruins,  examined  by  Dr.  Clarke,  was  eleven  pounds  the  pair,  or 

*  Comment.  Gottin.  1753. 


177 

five  and  a  half  each.  Twins  require  more  pabulum  from  the  mo- 
ther, and  a  greater  degree  of  action  in  the  uterus  ;  for  two  placen- 
tae must  have  their  functions  supported.  The  uterus  is  also  gene- 
rally more  distended,  and  produces  greater  irritation  ;  it  has  more 
blood  circulating  in  it ;  and  the  weight  of  its  contents,  to  thai  with 
a  single  child,  has  been  stated  as  twenty  to  fifteen.  Twin  gesta- 
tion often  produces  a  greater  effect  on  the  system,  making  the  wo- 
men more  disposed  to  disease,  and  less  able  to  bear  it :  hence  the 
chance  of  recovery  has  been  supposed  to  be  four  times  less  in 
them,  than  in  those  who  have  single  children.  The  children  be- 
ing generally  feebler  than  when  only  one  is  contained  in  the  ute- 
rus, are  more  disposed  to  disease ;  and,  as  the  mother  is  less  able 
to  suckle  children  after  a  twin  labour,  many  perish,  who  might 
have  been  preserved,  by  providing  a  good  and  careful  nurse,  soon 
after  birth,  for  the  weakest  child. 

When  the  number  of  children  increases  above  two,  the  aggre- 
gate weight  does  not  increase.  Thus  Dr.  Hull  of  Manchester  met 
with  a  delivery  of  five  children,  who  did  not  weigh  two  pounds  and 
a  quarter  ;  they  measured  from  eight  to  nine  inches  in  length,  and 
two  of  them  were  born  alive. 

Calculations  have  been  made  of  the  proportion  of  single  births, 
to  those  where  there  were  a  plurality  of  children.  In  the  Dublin 
hospital,  one  woman  in  fifty-eight  had  twins.  In  the  British  lying- 
in  hospital,  one  in  ninety-one.  In  the  Westminster  hospital,  one 
in  eighty.  In  my  own  practice,  about  one  in  ninety-five. 0?J  In 
the  Dublin  hospital,  triplets  have  not  occurred  above  once  in  five 


(/))  In  the  lying-in  hospital,  called  l'Hospice  de  la  Maternite",  at  Paris,  about 
one  in  eighty-nine  had  twins,  as  appears  from  Baudelocque's  Tableau  des  Ac- 
couchemens. 

In  the  lying-in  ward  of"  the  Philadelphia  alms-house,  as  appears  from  a  regular 
record  kept  for  19  years,  ending  1815,  one  woman  in  about  52  had  twins.  The 
proportion  of  males  to  females,  born  within  the  above  period,  was  about  10  males 
to  8  females. 

A  different  average,  particularly  as  it  regards  the  proportion  of  twin  cases,  was 
stated  in  the  former  edition  of  this  work,  but  that  was  taken  from  the  result  of 
five  J  ears  only,  in  which  twin  cases  had  very  rarely  occurred. 

24 


178 

thousand  and  fifty  umes.(q)     More  than  three  are  not  met  with, 
once  in  twenty  thousand  times. 

The  proportion  of  male  children,  born  in  single  births,  is  great- 
er than  of  females.  In  an  extensive  parish  in  this  place,  the  num- 
ber of  males  born  in  a  given  time,  was  to  that  of  females,  as  3716 
to  3177.  In  the  Westminster  hospital,  it  was  as  972  to  951 ;  but 
in  the  same  hospital,  it  is  worthy  of  remark,  that  the  number  of 
male  twins  was  only  16,  whilst  that  of  females  was  30.(VJ 

§  7.  PECULIARITIES  OF  THE  FOZTUS. 

The  foetus  has  many  peculiarities  which  distinguish  it  from  the 
adult,  and  which  are  lost  after  birth,  or  gradually  removed  during 
gestation.  In  particular,  the  liver  is  of  great  size,  by  which  the  ab- 
domen is  rendered  more  prominent  than  the  thorax.  It  appears 
very  early,  and  increases  rapidly  till  the  fourth  month,  after 
which  its  growth  is  slower.  In  the  child,  after  birth,  the  greatest 
quantity  of  blood  in  the  liver  is  venous,  and  from  this  the  bile 
seems  to  be  secreted.  But  in  the  foetus,  the  blood  is  more  nearly 
approaching  in  its  nature  to  arterial ;  and  no  bile,  but  a  fluid  dif- 
ferent in  its  properties,  is  secreted.  The  gall  bladder  is  filled  with 
a  green  fluid,  which,  before  birth,  becomes  darker,  with  a  tinge  of 
blue,  but  is  said  not  to  have  a  bitter  taste.  The  umbilical  vein, 
which  contains  blood,  changed  in  the  placenta,  enters  the  liver, 
and  sends  large  branches  to  the  left  side ;  the  vena  portae  enters  the 
liver,  and  ramifies  on  the  right  side  ;  whilst  a  branch,  or  canal  of 
communication,  is  sent  from  the  umbilical  vein  to  the  vena  portae. 
By  this  contrivance,  the  left  side  is  supplied  altogether  with  pure 
blood  from  the  placenta,  and  the  right  side  is  supplied  with  a  mix- 
ture of  pure  and  impure  blood,  which  does  not  form  perfect  bile. 
After  birth,  as  the  circulation  from  the  placenta  is  stopped,  the 
branches  of  the  umbilical  vein,  which  supplied  the  left  side,  would 
be  empty,  did  not  the  canal,  which  formerly  served  to  carry  a  por- 

(<7)  In  l'Hospice  de  la  Maternite  at  Paris,  triplets  occurred  but  twice  in  12,605 
women. 

())  Of  12,751  infants  born  in  the  lying-in  hospital  at  Paris,  above  alluded  to, 
6,524  were  males,  and  6,227  females. 


179 

lion  of  blood  from  this  vein  to  the  venaportae,  now  permit  this  lat- 
ter vessel  to  fill  the  branches  in  the  left  side,  which  henceforth 
form  a  part  of  the  vena  portae.  The  whole  liver  is  thus  supplied 
with  blood  entirely  venous.  Bile  is  formed,  and  sometimes  in 
very  considerable  quantity. 

The  blood  of  the  foetus  differs  from  that  of  the  adult.  It  forms  a 
less  solid  coagulum,  for  in  place  of  fibrous  matter,  it  yields  a  soft 
tissue,  almost  gelatinous.  It  is  not  rendered  florid  by  exposure  to 
air,*  and  it  contains  no  phosphoric  salt.  But  soon  after  the  foetus 
has  respired,  the  colouring  matter,  exposed  to  oxygen,  acquires  the 
vermilion  tint ;  and  salts  are  formed,  particularly  the  phosphate  of 
lime. 

The  stomach  is  smaller  in  the  foetus,  than  in  the  child  after 
birth.  The  intestines,  which  at  first  are  seen  like  threads  arising 
from  the  stomach,  are  redder,  and  said  to  be  longer  in  proportion 
to  the  body  in  the  foetus,  than  in  the  child.  They  are  at  first  un- 
covered, but,  after  some  time,  the  abdominal  muscles  and  integu- 
ments form  a  complete  inclosure.  They  contain  a  soft  substance 
like  ointment,  of  a  dark  green  colour,  called  meconium. 

The  testicles  of  the  male,  and  the  ovaria  of  the  female,  lie  on  the 
psoas  muscles;  but,  before  birth,  the  testicles  pass  into  the  scrotum. 
The  kidneys  are  large  and  lobulated,  and  the  ureters  thick.  The 
glandulae  renales  are  large,  and  contain  a  reddish  fluid.  The  blad- 
der is  more  conical  and  lengthened  than  in  the  adult.  The  lungs 
are  dense  and  firm,  and  a  large  gland,  called  thymus,  is  contained 
in  the  thorax.  The  heart  is  very  different  from  its  adult  state.  In 
the  chick,  we  find  that  there  is  in  the  situation  of  the  heart,  a  single 
cavity  which  afterwards  corresponds  to  the  left  ventricle.  At  the 
forty-sixth  hour  the  ventricle  and  bulb  of  the  aorta  are  visible. 
Then  an  auricle  is  formed  by  the  vena  cava  :  this  auricle  does  not 
adhere  directly  to  the  ventricle,  until  the  sixth  day,  but  is  connect- 
ed with  it  till  that  time  by  a  short  duct,  called  canalis  auricularis. 
In  about  ninety-six  hours  the  auricle  begins  to  exhibit  marks  of  a 
division  into  two  cavities,  or  a  right  and  left  side,  and  some  time 
afterwards,  the  right  ventricle  and  lungs  are  evolved.     The  struc- 

*  Bichat  made  experiments  to  ascertain  this  upon  Guinea  pigs,  and  always 
found  the  fetal  blood  black.    Anatomie  Generale,  Tome  II.  p.  343. 


180 

lure  of  the  heart,  however,  is  still  different  from  that  which  obtains 
after  birth ;  for  though  the  auricles  are  divided  into  two  cavities,  yd 
these  are  seen,  in  the  human  foetus,  to  communicate  freely  by  a 
vacancy  in  the  septum  ;  and  even  after  this  is  supplied,  it  is  only 
with  a  valve,  which  allows  the  blood  to  pass  from  the  right  to  the 
left  side.  This  is  the  foramen  ovale,  which  is  shut  up  after  birth. 
Another  peculiarity  of  the  foetal  heart  is,  that  the  pulmonary  artery, 
although  it  divide  into  two  branches  for  the  lungs,  yet  sends  a  third, 
and  still  larger  branch,  directly  into  the  aorta  just  at  its  curvature, 
and  this  is  the  ductus  arteriosus.  The  blood  is  received  in  a  puri- 
fied state  from  the  placenta,  by  the  umbilical  vein,  which,  after 
giving  off  branches  in  the  liver,  sends  forward  the  continuation  of 
the  trunk,  to  terminate  in  the  vena  cava,  or  largest  of  the  hepatic 
veins,  and  this  continuation  is  named  ductus  venosus.  The  mixed 
blood  which  is  thus  found  in  the  vena  cava,  is  carried  to  the  right 
auricle,  and  thence  to  the  corresponding  ventricle.  By  the  pulmo- 
nary artery  it  ought  to  be  conveyed  to  the  lungs,  but  this  would  be 
useless  in  the  foetus,  and  therefore  the  greatest  part  of  it  passes  on 
by  the  ductus  arteriosus  to  the  aorta.  But  it  follows  from  this,  that 
as  little  blood  is  carried  to  the  lungs,  so  little  can  be  brought  from 
them  by  the  pulmonary  veins  to  the  left  auricle.  Now,  to  obviate 
this,  and  fill  that  auricle  at  the  same  time  with  the  right,  the  fora- 
men ovale  is  formed ;  and  thus,  as  the  blood  can  pass  freely  from 
the  right  to  the  left,  the  two  auricles  are  to  be  considered  as  one 
cavity,  being  filled  and  emptied  at  the  same  time. 

The  aorta  is  distributed  to  the  different  parts  of  the  body ;  but 
this  singularity  prevails,  that  the  hypogastric  vessels  run  up  all  the 
way  to  the  navel,  and  pass  out  to  form  the  umbilical  arteries.  Af- 
ter birth,  these  arteries  are  obliterated  in  their  course  to  the  navel ; 
and  the  foramen  ovale,  and  ductus  arteriosus  become  impervious. 

The  head  of  the  foetus  is,  at  first,  membranous,  and  the  brain  a 
pulp,  soluble  in  aqua  kali  puri.  By  degrees,  distinct  cartilaginous 
plates  are  formed  over  the  brain,  which  are  gradually  converted  in- 
to bones.  These,  at  birth,  are  only  united  by  intermediate  mem- 
branes. 

The  pupil  of  the  eye,  till  the  seventh  month,  is  shut  up  by  a 
membrane ;  and  the  eyelids,  for  some  months,  adhere  together. 


181 

The  skin  is  covered  with  a  white  substance,  which,  though  une- 
tious  to  the  feel,  does  not  melt,  but  dries  and  crackles  by  heat.  It 
is  miscible  with  spirits,  or  with  water,  through  the  medium  of  soap 
or  of  oil. 

The  male  foetus  differs  from  the  female,  in  having  the  head  larger, 
but  less  rounded,  and  flatter  at  the  back  part.  The  thorax  is  longer, 
and  more  prominent,  and  formed  of  stronger  ribs  than  in  the  fe- 
male. In  her,  it  is  wider  from  the  upper  part  to  the  fourth  rib,  and 
narrower  below;  the  belly,  also,  in  the  female,  is  more  prominent, 
and  the  symphysis  pubis  projects  more.  The  upper  extremities 
are  shorter  than  those  in  the  male ;•  the  thighs  are  thicker  at  the  top, 
and  more  tapering  to  the  knees.  Dr.  Soemmering  says,  that  the 
spinous  processes  of  the  lower  dorsal,  and  upper  lumbar  vertebrae, 
make  in  the  male  an  eminence  like  a  yoke,  in  the  female  a  sinuo- 
sity. I  may  remark,  that  as  the  clitoris  is  large  in  the  young  foetus, 
females  sometimes  pass  in  abortions  for  males. 

When  in  utero,  the  foetus  assumes  that  posture  which  occupies 
least  room.  The  trunk  is  bent  a  little  forward,  the  chin  is  pushed 
down  on  the  breast,  the  knees  are  drawn  up  close  to  the  belly,  and 
the  legs  are  laid  along  the  back  part  of  the  thighs,  with  the  feet 
crossing  each  other.  The  arms  are  thrown  into  the  vacant  space 
betwixt  the  head  and  knees.  This  is  the  general  position,  and  the 
child  thus  forms  an  oval  figure,  of  which  the  head  makes  one  end, 
and  the  breech  the  other.  One  side  of  it  is  formed  by  the  spine  and 
back  part  of  the  head  and  neck,  and  the  other  by  the  face  and  con- 
tracted extremities.  The  long  axis  of  this  ellipse  measures,  at  the 
full  time,  about  ten  inches,  and  the  short  one,  five  or  six.  In  the 
eighth  month,  the  long  axis  measures  about  eight  inches.  In  the 
sixth,  betwixt  four  and  five.  In  the  fourth  month,  it  measures 
nearly  three  inches  and  a  half;  and  in  the  third,  about  an  inch  less. 

In  the  early  months,  however,  there  is  no  regular  oval  formed, 
and  these  measurements  are  taken  from  the  head  to  the  breech, 
which  afterwards  forms  the  ends  of  the  distinct  ellipse.  The  ex- 
tremities are  at  first  small  and  slender,  and  bend  loosely  toward 
the  trunk. 


182 


§  8.  UMBILICAL  CORD.  i 

The  umbilical  cord  is  an  essential  part  of  the  ovum,  connecting 
the  fetus  to  its  involucra.  It  is  found  in  oviparous  and  viviparous 
animals,  and  also  in  plants ;  but  in  these  different  classes,  it  ap- 
pears with  many  modifications.  In  the  human  subject,  it  consists 
of  three  vessels  ;  of  which  two  are  arteries,  and  one  is  a  vein. 
These  are  imbedded  in  gluten,  and  covered  with  a  double  mem- 
branous coat.  The  two  arteries  are  continuations  of  the  arteriae 
hypogastrics  of  the  child,  and  passing  out  at  the  navel,  run  in  dis- 
tinct and  unconnected  trunks,  until  they  reach  the  placenta,  where 
they  ramify  and  dip  down  into  its  substance.  When  they  reach  the 
placenta,  the  one  artery,  in  some  cases,  sends  across  a  branch  to 
communicate  with  the  other.  The  vein  commences  in  the  sub-„ 
stance  of  the  placenta,  forms  numerous  rays  on  its  surface,  corres- 
ponding to  the  branches  of  the  arteries ;  and  near  the  spot  where 
the  arteries  begin  to  give  off  branches,  these  rays  unite  into  a  sin- 
gle trunk,  the  area  of  which  is  rather  more  than  that  of  the  two  ar- 
teries.    None  of  these  vessels  are  furnished  with  valves. 

The  umbilical  vessels  run  in  a  spiral  direction,  within  the  co- 
vering of  the  cord,  and  the  twist  is  generally  from  right  to  left. 
Besides  this  twisting,  we  also  find,  that  the  vessels,  especially  the 
arteries,  form  very  frequently  coils,  loosely  lodged  in  the  gluten. 

The  cord  does  not  consist  entirely  of  vessels,  but  partly  of  a 
tenacious  transparent  gluten,  which  is  contained  in  a  cellular  struc- 
ture; and  these  numerous  cells,  together  with  the  vessels,  are 
covered  with  a  sheath,  formed  by  the  reflection  of  both  chorion 
and  amnion  from  the  placenta ;  and  of  necessity  the  amnion  forms 
the  outer  coat  of  the  cord.  The  chorion  adheres  firmly  to  the  cord 
every  where,  but  the  amnion  does  not  adhere  to  the  chorion;  it  is 
not  even  in  contact  with  it  at  the  placental  extremity,  but  forms 
there  a  slight  expansion,  which,  from  its  shape,  has  been  called  by 
Albinus,  the  processus  infundibuliformis. 

The  proportion  of  gluten  is  larger  in  the  early  than  in  the  ad- 
vanced stage  of  gestation ;  and  the  vessels,  at  first,  run  through  it 
in  straight  lines.     In  some  instances,  the  cells  distend  or  augment 


183 

in  number,  so  as  to  form  tumours  on  the  cord,  which  hang  from 
it  like  a  dog's  ear. 

There  is  a  small  sac,  or  bladder,  found  on  the  placenta,  at  or 
near  the  extremity  of  the  cord,  in  the  early  part  of  gestation.  It  is 
most  distinct  betwixt  the  third  and  fourth  month  of  pregnancy,  and 
is  placed  exterior  to  the  amnion.  It  is  filled,  though  not  quite  dis- 
tended, with  a  whitish  fluid,  on  which  account  it  is  called  the  ve- 
sicula  alba.*  From  this  a  very  fine  vessel  proceeds  along  the  cord, 
adhering  firmly  to  the  amnion;  but,  without  a  glass,  it  cannot  be 
traced  all  the  way  to  the  navel.  It  has  been  supposed  to  be  sub- 
servient to  the  nourishment  of  the  foetus  in  its  early  stage.  A  small 
artery  and  vein  pass  along  the  cord  from  the  navel,  to  the  vesicle 
which  is  between  the  chorion  and  amnion.  These  are  the  ompha- 
lo-mesenteric  vessels. 

Besides  the  blood  vessels,  there  is  in  brutes  another  vessel, 
which  is  a  continuation  of  the  fundus  vesicae.  It  passes  out  at  the 
navel,  and,  running  along  the  cord,  terminates  in  a  bag,  which  is 
placed  betwixt  the  chorion  and  amnion.  The  bag  is  called  the 
allantois,  and  the  duct  the  urachus.  In  the  human  subject,  in  place 
of  the  urachus,  we  find  only  a  small  white  impervious  cord.  There 
is  of  course  no  allantois. 

When  the  ovum  is  first  visible  in  the  uterus,  there  is  no  cord, 
the  embryo  adhering  directly  to  the  involucra,  but  it  soon'recedes ; 
and  about  the  sixth  week,  a  cord  of  communication  is  perceptible. 

The  cord  at  the  full  time  varies  in  length,  from  six  inchesf  to 
four  feet;t  but  its  usual  length  is  two  feet.  When  it  is  too  long, 
it  is  often  twisted  round  the  neck  or  body  of  the  child,  or  occa- 
sionally has  knots  formed  on  it,^  most  frequently,  perhaps,  by  the 
child  passing  through  a  coil  of  it  during  labour.  || 


*  Vide  Albinus,  Annot.  Acad.  lib.  I.  cap.  six.  p.  74,  et  tab.  I.  fig.  12. 

f  Hildanus,  cent.  II.  obs.  50. 

i  Mauriceau  has  seen  it  a  Paris  ell  and  a  third,  obs.  401.— Hebenstreit  40 
inches.— Haller  Disp.  Anat.  Tom.  V.  p.  675.— Wrisberg  48  inches.— Tide  Com. 
Gotting.  Tom.  IV.  p.  60. 

§  Vide  Mauriceau,  obs.  133.  and  156. 

1  Dr.  Hunter  thinks  he  has  twice  seen  these  formed  previous  to  birth, 


184 

The  vessels  of  the  cord  sometimes  become  varicose,  and  form 
very  considerable  tumours.  These,  occasionally,  so  far  impede 
the  circulation,  as  to  interfere  with  the  growth  of  the  child,  or  even 
to  destroy  it  altogether.  Sometimes  the  vessels  burst,  and  blood 
is  poured  into  the  uterus,  which  produces  a  feeling  of  distention, 
and  excites  pain.  There  can,  however,  be  no  certainty  of  this  ac- 
cident having  taken  place  until  the  membranes  burst,  when  clots 
of  blood  are  discharged.  If  the  fcetal  and  maternal  vessels  should 
communicate,  the  mother  is  weakened,  and  may  even  faint;  and, 
in  every  instance,  the  child  suffers,  but  does  not  always  die.*  De- 
livery must  be  resorted  to,  either  on  account  of  the  effects  pro- 
duced on  the  mother,  or  to  prevent  the  destruction  of  the  child. 

The  cord  may,  by  a  fall,  or  violent  concussion  of  the  body,  be 
torn  at  a  very  early  period  of  gestation.  In  this  case,  the  child 
dies,  but  is  not  always  immediately  expelled  It  may  be  retained 
for  several  weeks ;  afterwards  the  ovum  is  thrown  off,  like  a  con- 
fused mass,  inclosing  a  foetus,  corresponding  in  size  to  the  period 
when  the  accident  happened.f  The  cord  may  be  filled  with 
hydatids. 

The  cord  has  been  found  unusually  small  and  delicate,  or,  on 
the  contrary,  very  thick.  In  the  latter  case,  it  is  always  proper  to 
apply  two  ligatures,  instead  of  one,  on  the  portion  which  remains 
attached  to  the  child.J  It  has  happened,  that  by  the  shrinking  of 
the  cord  under  the  ligature,  the  child  has  died  from  hemorrhage.^ 

Two  cords  have  been  met  with,  connected  with  one  placenta, 
or  with  two  placentae  belonging  to  one  child.  In  other  instances, 
the  vessels  are  supernumerary  or  deficient.  Stories  have  been 
told  of  the  cord  being  altogether  wanting,  but  these  are  incompati- 
ble with  the  fcetal  economy. 

•  Vide  Baudelocque  PArt,  note  to  section  1084. 
•J-  Vide  Case  by  M.  Anel,  in  Mem.  of  Acad,  of  Sciences,  1714. 
+  This  was  proposed  by  Mauriceau,  in  consequence  of  meeting  with  an  i>> 
stance,  where  the  child  suffered  much  from  loss  of  blood,  obs.  256. 
§  Vide  Case  by  M.  Degland,  in  Recueil  Period.  Tome  V.  p.  343. 


185 


§  9.  PLACENTA. 

A  placenta,  or  something  equivalent  to  it,  is  to  be  found  con- 
nected with  the  young  of  every  living  creature. 

We  find  it  requisite  that  a  pabulum  should  be  supplied  to  every 
animal,  and  that  certain  changes  should  be  performed  on  the  blood, 
qualifying  it  for  supporting  life.  In  oviparous  animals,  two  differ- 
ent parts  of  the  ovum  perform  these  separate  functions.  The  um- 
bilical vessels  of  the  chick  ramify  on  the  membrane  of  the  albu- 
men, and  thus  come  in  contact  with  the  air,  which  is  absorbed 
through  the  pores  of  the  shell ;  and,  by  this  contrivance,  changes 
analagous  to  those  effected  by  respiration,  are  produced  on  the 
blood.  From  the  inner  surface  of  the  membrane  of  the  vitellus, 
a  nourishing  fluid  is  absorbed,  which  is  conveyed  to  the  intestine 
by  a  proper  duct ;  and,  before  the  chick  is  hatched,  the  remainder 
of  this  fluid,  inclosed  in  the  membrane  of  the  vitellus,  is  taken 
within  the  abdomen,  and  covered  with  the  abdominal  integu- 
ments.* 

*  In  the  eggs  of  fowls,  we  observe  the  following  circumstances.  1st.  Upon 
removing  the  porous  shell,  we  find  the  albumen  inclosed  in  a  membrane,  consist- 
ing of  two  layers,  and  called  sacciform  by  Levielle.  These  are  separated  from 
each  other  at  the  large  end  of  the  shell,  so  as  to  form  a  small  sac,  called  the  fol- 
liculus  aeris.  The  albumen  is  divided  into  three  strata  ;  the  first,  or  cortical,  is 
most  liquid  ;  the  second  or  middle,  is  more  abundant,  and  thicker  than  the  first, 
but  less  so  than  the  third  or  central.  The  middle  and  central  strata  are  inclosed 
in  a  delicate  membrane,  called  leucilyme  by  Levielle,  which  separates  them  from 
the  cortical.  2d.  Within  the  albumen  we  have  the  vitellus  or  yolk,  which  is  in- 
closed in  a  vascular  membrane,  called  chlorilyme,  or  membrana  vitelli,  which 
again  is  enveloped  by  a  membrane  common  to  it  and  the  intestines  of  the  chick, 
called  entro-chlorilyme.  3d.  To  each  end  of  the  vitellus,  we  have  connected  a 
portion  of  the  central  albumen,  called  chalaza ;  and  in  each  of  these  a  membra- 
nous substance  is  discovered,  attached  to  the  membrane  of  the  vitellus,  and  a  vas- 
cular structure,  which  can  absorb  the  albumen  into  the  vitellus,  to  contribute  to 
the  nutrition  of  the  chick.  4th.  Upon  the  vitellus,  we  observe  the  cicatricula,  or 
small  sac,  called  by  Harvey  the  eye  of  the  egg,  and  which  was  supposed  to  con- 
tain the  foetus,  the  rudiments  of  which  are  allowed  by  Malpighi,  Haller,  and 
Spallanzani,  to  be  pre-existent  to  fecundation.  This  cicatricula  was  considered 
as  analogous  to  the  amnion,  and  supposed  to  contain  a  transparent  fluid,  called  by 
Harvey  colliquamentum  candidum,  or  liquor  amnii.    More  modern  observations 

£5 


186 

la  many  quadrupeds  we  find,  that,  after  impregnation,  certain 
portions  of  the  inner  surface  of  the  uterus  enlarge,  and  form  pro- 
ascertain  that  the  embryo  is  not  formed  in  the  cicatricula,  but  very  near  it  on 
the  vitellus,  and  that  the  amnion  inclosing  it  can  at  first  scarcely  be  distinguished 
from  the  embryo.  The  cicatricula  soon  disappears.  Harvey's  account  must 
therefore  be  transferred  to  the  amnion.  5th.  During  incubation,  the  vitellus  be- 
comes specifically  lighter  than  the  albumen  ;  and  rises  toward  the  folliculusaeris. 
Two  arteries  and  two  veins  go  from  the  meseraic  and  hypogastric  vessels  of  the 
foetus,  to  the  membrane  of  the  yolk,  and  are  supposed  to  absorb  the  vitellus, 
which  therefore  is  carried  to  the  vena  porta:  of  the  chick,  and  nourishes  the 
foetus.  There  is  also  a  connection  betwixt  the  intestines  and  vitelline  membrane, 
by  means  of  a  ligamentous  substance,  which  was  supposed  by  Haller  and  Vicq. 
D'Azyr  to  be  a  tube,  and  called  vitello-intestinal  canal,  for  it  is  said  that  air  has 
been  passed  through  it.  It  was  supposed  to  absorb  the  yolk,  by  many  villi  on 
the  inner  surface  of  the  vitelline  membrane ;  but  these  are  said  by  Levielle  not 
to  be  vessels,  but  soft  lamellated  plates.  At  the  end  of  the  second  day,  red  blood 
is  observed  on  the  membrana  vitelli.  A  series  of  dots  are  formed,  which  are  con- 
verted first  into  grooves,  and  then  into  vessels,  which  go  to  the  foetus.  This  ap- 
pearance has  been  called  figura  venosa,  and  the  marginal  vessel  vena  terminalis. 
6th.  The  vitello-intestinal  ligament,  and  these  vessels,  form  an  umbilical  cord. 
But  besides  these,  we  find,  after  the  fourth  day,  a  vascular  membrane  at  the  um- 
bilicus, called  membrana  umbilicalis,  which  rapidly  increases,  and  comes  pre- 
sently to  cover  the  inner  surface  of  the  membrane  of  the  shell.  It  is  the  chorion, 
and  has  numerous  vessels  ramifying  on  it,  like  the  chorion  of  the  sow,  and  con- 
nected in  like  manner  with  the  foetus.  The  blood  of  the  umbilical  artery  is  dark- 
coloured,  that  of  the  vein  bright.  7th.  As  incubation  advances,  the  amnion  en- 
larges, and  comes  in  contact  every  where  with  the  chorion.  The  albumen  is  all 
consumed,  being  taken  into  the  vitellus,  which  is  in  a  great  measure  absorbed  ; 
and  what  remains  is  taken,  together  with  the  sac,  into  the  abdomen  of  the  chick, 
and  the  parietes  close  over  it.  On  the  21st  day,  the  chick  breaks  the  shell  and 
escapes.  By  increasing  or  diminishing  the  temperature  within  a  certain  extent, 
the  process  may  be  somewhat  accelerated  or  retarded.  The  eggs  of  large  birds 
require  a  longer  time  to  be  hatched  ;  those  of  the  ostrich,  for  example,  take  six 
weeks. 

Hence  it  appears,  that  the  vitellus  and  albumen  contribute  to  the  increment  of 
the  fcctus,  whilst  the  exterior  membranes  act  as  lungs,  the  air  being  transmitted 
through  the  pores  of  the  shell. 

The  eggs  of  fishes  have  a  general  resemblance  to  those  of  fowls,  and  consist  of 
a  vitellus  and  albumen,  with  their  membranes;  but  in  place  of  being  furnished 
with  a  shell,  they  have  a  tough,  or  sometimes  a  horny  covering ;  and  some,  as 
those  of  the  shark,  torpedo,  &c.  are  quadrangular  in  shape.  The  yolk  is  connect- 
ed to  the  intestines  of  the  foetus,  and  its  membrane  is  very  vascular.  As  in  fowls, 
so,  in  fishes,  it  is  ultimately  inclosed  within  the  abdomen  of  the  young.  In  the 
skate,  numerous  blood  vessels  are  formed  in  the  albumen,  which  supply  the  place 


137 

tuberances,  having  many  hollows  or  foramina,  from  which  a  milky 
fluid  can  be  squeezed.     From  the  chorion,  corresponding  vascular 

of  gills,  and  are  supposed  by  Dr.  Monro,  to  be  afterwards  covered  and  converted 
into  gills.  The  two  functions  of  a  placenta,  then,  are  still  more  distinctly  fulfilled 
here  than  even  in  fowls,  for  the  apparatus  for  nutrition  and  respiration  has  dif- 
ferent or  distinct  terminations ;  whereas  in  fowls  and  quadrupeds,  all  the  vessels 
enter  at  one  place.  A  similar  fact  is  observed  in  the  ova  of  frogs,  for  the  umbilical 
cord  in  the  tadpole  goes  to  the  head. 

The  egg  of  the  serpent  is  nearly  the  same  with  that  of  the  fish,  and  is  inclosed 
in  a  flexible  membrane.  The  foetus  is  coiled  up  spirally  within  it,  and  the  chorion 
is  vascular,  as  in  the  egg  of  the  fowl. 

The  adder  is  a  viviparous  animal;  its  uterus  is  membranous,  and  divided,  I  find, 
into  eight  or  nine  cells,  each  of  which,  in  September,  contains  an  ovum  as  large  as 
a  chesnut.  This  consists  of  an  exterior  membrane,  which  incloses  a  foetus  about 
six  inches  long,  and  coiled  up.  About  an  inch  from  the  tail,  the  umbilical  cord 
passes  out,;  which  consists  of  vessels  that  go  to  ramify  on  the  exterior  membrane, 
which  resembles  the  chorion  of  the  sow.  There  is  also  a  connection  with  a  vitel- 
lus,  which  is  as  large  as  a  hazel  nut. 

The  coluber  natrix  is  said,  by  Valmont-Bomare,  to  have  a  placenta  and  cord 
within  the  egg,  but  this  is  contrary  to  the  general  structure  of  eggs ;  most  likely 
the  chorion  has  been  taken  for  the  placenta.  The  eggs  of  reptiles  are  often  de- 
posited in  packets,  the  eggs  being  glued  together. 

The  egg  of  the  turtle  is  as  large  as  a  hen's,  and  is  inclosed  in  a  covering  like 
parchment.  It  is  deposited  in  the  sand,  and  is  hatched  in  about  24  days.  The  egg 
of  the  alligator  is  similar  in  structure  to  that  of  the  turtle  :  it  is  rather  larger  than 
a  goose's  egg,  and  covered  with  a  thin  skin,  so  transparent,  however,  that  the 
foetus  may  be  seen  through  it. 

Those  animals  which  are  called  oviparous,  hatch  their  eggs  out  of  the  body, 
either  by  sitting  on  them,  as  we  see  in  fowls,  or  by  exposing  them  to  the  heat  of 
the  sun,  as  the  turtle,  crocodile,  and  many  serpents.  Oviparous  fishes,  which 
comprehend  all  those  called  osseous,  expel  their  ova  into  the  water,  where  they 
are  fecundated  by  the  male,  but  without  copulation.  Many  fishes  leave  the  sea, 
and  come  up  the  rivers  to  spawn.  Others  remain  in  the  ocean  ;  and  the  eg-gs, 
specifically  lighter  than  the  water,  float  on  the  surface.  Many  fishes  attach  them 
to  marine  plants,  and  in  some  cases  the  ova  are  fixed  to  the  body  of  the  pa- 
rent. The  ova  are  covered  with  a  kind  of  mucus,  which  has  been  supposed  to 
defend  them  from  the  water. 

The  ova  of  frogs,  &c.  are  likewise  fecundated  and  hatched  out  of  the  body. 
They  are  enveloped  in  a  glairy  matter,  which  perhaps  contributes  to  their  in- 
crease ;  for  during  incubation,  the  egg  both  enlarges  and  changes  its  shape. 

Those  animals  which  hatch  their  eggs  within  the  body,  are  called  ovo-vivipa- 
rous,  such  as  cartilaginous  fishes,  as  the  shark,  skate,  and  torpedo,  &c.  The  scor- 
pion and  venemous  serpents  also  belong  to  this  class.  Ovo-viviparous  animals  ex- 
pel the  young  fully  formed,  and  therefore  have  been  sometimes  considered  as 


188 

efflorescences  arise,  which  shoot  into  these  apertures;  and  thus  an 
union  is  effected  betwixt  the  mother  and  foetus. 

having  uteri  like  quadrupeds,  and  a  cord  attached  directly  to  it.  Spallanzani  at 
first  supposed  that  the  foetus  of  the  torpedo  was  attached  directly  to  the  uterus, 
but  afterwards  found  that  it  was  contained  in  a  distinct  ovum.  Experiences,  p. 
294.  See  also  Cuvier  Lecons  d'Anat.  Comparee,  Tom.  V.  p.  142.  The  shark 
is  said  to  have  an  uterus  like  the  bitch,  and  Belon  says  he  saw  a  female  deliver- 
ed of  eleven  young  attached  by  a  cord.  Its  mode  of  gestation  most  likely  is  simi- 
lar to  the  torpedo.  This  class  expel  their  young  often  very  quickly.  A  female 
syngnatus  hyppocampus  was  observed  to  expel  at  least  a  hundred  in  a  very  short 
time. 

Analogous  to  ovo-viviparous  animals,  are  those  which  receive  the  ova  into  cells 
on  the  surface  of  the  body,  where  they  are  hatched.  This  is  well  seen  in  the 
pipa,  a  species  of  toad.  Even  the  tadpoles,  are  said  to  be  metamorphosed  in  these 
cells.  The  opossum  tribe  has  a  modification  of  this  gestation ;  for  in  them  the 
foetus,  when  very  small,  is  expelled  into  a  bag  situated  on  the  belly,  and  imme- 
diately attaches  itself  to  a  nipple.  The  utero-gestation  of  the  opossum  of  North 
America  lasts  only  from  20  to  26  days,  and  the  embryo,  when  expelled,  does  not  - 
exceed  a  grain.  It  remains  in  the  sac  about  50  days,  and  acquires  the  size  of  a 
mouse.  In  other  animals,  as  for  instance  the  bat,  the  young,  after  birth,  attach 
themselves  to  the  nipple,  partly  for  the  convenience  of  being  transported  or  car- 
ried about. 

In  plants  we  find  likewise  a  placenta  or  structure,  intended  for  the  nourishment 
and  respiration  of  the  foetus.  To  take  the  kidney  bean  for  an  example,  wTe  find 
within  the  membranous  covering  two  parenchymatous  lobes,  or  cotyledons ;  and 
at  the  margin  betwixt  these,  there  is  the  corculum  or  cicatricula.  During  incu- 
bation, we  find  that  this  sends  up  a  small  shoot  called  the  plumula,  and  down  a 
radical  into  the  earth.  But  to  support  the  plant  until  the  root  and  leaves  are  ca. 
pable  of  maintaining  it,  we  find  the  cotyledons  rise  up  out  of  the  earth,  on  each 
side  of  the  plumula,  forming  what  are  called  seed  leaves.  These  both  serve  for 
the  respiratory  organs,  and  also  supply  pabulum,  which  is  absorbed  by  proper 
vessels,  and  in  consequence  thereof  they  presently  are  destroyed.  When  there 
are  more  lobes  than  two  in  the  seed,  there  are  a  corresponding  number  of  seed 
leaves.  In  many  cases  these  cotyledons  do  not  rise  out  of  the  ground,  but  the 
plumula  alone  appears.  This  is  the  case  with  the  garden  pea,  but  the  cotyledons 
still  perform  their  functions  below  the  ground,  and  exist  until  the  foliage  of  the 
plant,  or  adult  organs,  be  formed.  The  greatest  part,  then,  of  a  vegetable  seed 
or  ovum,  consists,  like  the  eggs  of  fowls,  of  an  apparatus  intended  for  the  nutri- 
ment and  respiration  of  the  foetus,  whilst  the  embryo  itself  is  very  small.  The 
cotyledon  consists,  in  many  cases,  of  a  farinaceous  substance.  In  other  seeds  it 
is  oily  and  farinaceous,  and  in  some  is  almost  all  oily. 

Vegetable  ova  sometimes  are  contained  in  a  dry  pericarpium,  and  are  shed  in- 
to the  earth  when  it  bursts.  But  others  have  an  apparatus  provided,  not  only  for 
their  present  growth,  but  also  for  accelerating  their  incubation  in  the  earth.    In 


189 

In  the  sow  and  the  mare  there  is  no  projection  from  the  uterus, 
but  its  surface  is  every  where  smooth  and  vascular.  There  is  no 
efflorescence  from  the  chorion,  but  it  has  numerous  vessels  dispo- 
sed over  it,  which  are  the  extremities  of  the  umbilical  arteries  and 
veins.  In  these  animals,  then,  we  have  no  distinct  placenta,  the 
chorion  alone  serving  that  purpose. 

The  cetaceae  have  uteri  like  quadrupeds,  but  I  am  unacquainted 
with  the  precise  mode  of  connection  betwixt  the  mother  and  the 
foetus. 

The  monkey  differs  from  other  quadrupeds,  in  having  no  perma- 
nent papillae ;  but  the  maternal  part  of  the  placenta  is  deciduous, 
like  that  of  women. 

In  the  human  subject,  the  placenta  is  a  flat  circular  substance 
about  a  span  in  diameter,  and,  when  uninjected,  an  inch  in  thick- 
ness. It  becomes  gradually  thinner  from  the  centre  to  the  circum- 
ference, by  which  it  ends  less  abruptly  in  the  membranes.  Its 
common  shape  is  circular;  but  it  is  sometimes  oblong,  or  divided 
into  different  portions. 

The  umbilical  cord  may  be  fixed  into  any  part  of  the  placenta, 
or  sometimes  into  the  membranes,  at  a  distance  from  the  placenta. 
When  this  happens,  the  vessels  run  in  distinct  branches  to  the  pla- 
centa, without  forming  any  spongy  substance  on  the  membranes. 
Most  frequently,  however,  the  cord  is  inserted  at  a  point  about  half 
way  between  the  centre  and  the  circumference  of  the  placenta. 
From  this  the  umbilical  vessels   spread  out,  like  a  fan,  ramifying 


stone  fruit  and  nuts,  we  find  that  vessels  pierce  the  shell  at  the  bottom,  and  pass 
on  toward  the  top,  and  reach  the  kernel  or  lobes,  which  are  contained  within  the 
shell,  enveloped  in  a  soft  membrane.  They  are  inserted  very  near  the  embryo. 
Now,  for  the  farther  support  of  these  parts,  we  find  that  stone  fruits  are  covered 
with  a  quantity  of  nutritious  matter.  The  almond,  for  example,  has  its  ligneous 
nut  covered  with  a  fleshy  substance  about  an  inch  thick,  inclosed  in  a  proper 
membrane.  The  rhamnus  lotus  has  the  stone  surrounded  with  farinaceous  matter, 
which  tastes  like  gingerbread.  Other  seeds  are  contained  in  a  parenchymatous 
or  succulent  substance,  as  the  apple  or  pear;  or  in  a  firm  white  substance,  like 
cream  or  marrow,  or  in  a  mucilaginous  matter  as  the  gooseberry,  or  in  an  orgam 
zed  pulp  as  the  orange  and  garcinia  mangostona.  Some  are  deposited  in  a  lus- 
cious fluid  at  first,  which  ultimately  becomes  farinaceous,  as  the  plaintain. 


190 

over  the  surface,  and  dipping  their  extremities  into  the  substance 
of  the  placenta  itself. 

That  surface  of  the  placenta  which  is  attached  to  the  uterus,  is 
divided  into  lobes,  with  slight  sulci  between  them,  and  is  covered 
with  a  layer  of  the  decidua  like  clotted  blood.  On  the  surface 
which  is  next  the  child,  we  see  the  eminent  branches  of  the  umbi- 
lical vessels,  over  which  we  find  spread  the  chorion  and  amnion. 

If  we  inject  from  the  umbilical  vessels  of  the  human  foetus,  we 
find  that  the  placenta  is  rendered  turgid,  and  vessels  are  to  be  found 
filled  in  every  part  of  it;  but  always  between  their  ramifications 
there  remains  an  uninjected  substance  ;  even  the  uterine  surface  of 
the  placenta  is  not  injected,  for  the  foetal  vessels  do  not  pass  all  the 
way  to  that  surface. 

If  we  inject  from  the  uterine  arteries,  we,  in  like  manner,  ren- 
der the  placenta  turgid,  but  nothing  passes  into  the  umbilical  vessels ; 
and  when  we  cut  into  the  placenta,  we  find  cells  full  of  injection, 
and  covered  with  a  fibrous  uninjected  matter.  Hence  we  may  in- 
fer that  the  placenta  consists  uniformly  of  two  portions.  The  one 
is  furnished  by  the  deciduous  coat  of  the  uterus,  the  other  by  the 
vessels  of  the  chorion  ;  and  these  two  portions  may,  during  the 
first  three  months,  be  separated,  by  maceration,  from  each  other. 

The  structure  of  the  foetal  portion,  so  far  as  we  know,  appears 
to  be  similar  to  that  of  the  pulmonary  vessels,  the  artery  terminat- 
ing in  the  vein.  But  the  other  portion  is  somewhat  different; 
there  is  not  a  direct  anastomosis,  but  the  artery  opens  into  a  cell, 
and  the  vein  begins  from  this  cell ;  for,  by  throwing  in  wax  by  the 
uterine  artery,  we  may  frequently  inject  the  veins.  These  cells 
communicate  freely  with  each  other  in  every  part  of  the  placenta, 
and  may  be  compared  to  the  corpora  cavernosa  penis. 

From  the  general  principles  of  physiology,  as  well  as  from  ex- 
periments on  the  chick  in  ovo,  and  from  the  fatal  effects  which  in- 
stantly follow  compression  of  the  cord  whilst  the  child  is  in  utero, 
it  is  allowable  to  infer,  that  the  placenta  serves  to  produce  a  change 
on  the  blood  of  the  foetus,  analagous  to  that  which  the  blood  of 
the  adult  undergoes  in  the  lungs  ;  and  from  considering,  that  the 
foetus  itself  cannot  create  materials  for  its  own  growth  and  support, 


191 

we  may  farther  infer,  that  the  placenta  is  the  source  of  nutrition 
also. 

The  placenta  may  be  formed  at  any  part  of  the  uterus,  but,  in 
general,  it  is  found  attached  near  the  fundus. 

Its  structure  is  sometimes  changed,  part  of  it  being  ossified  or 
indurated,  or  on  the  contrary,  unusually  soft.  These  changes  may 
produce  either  hemorrhage,  or  retention  of  the  placenta.  Hyda- 
tids may  form  in  the  placenta  ;  or  fleshy  tumours  may  grow  in  its 
substance.  In  neither  of  these  cases  does  the  child  necessarily 
die. 

§  10.  MEMBRANES  AND  LIQUOR  AMN1I. 

The  ovum  when  it  descends  into  the  uterus,  consists  of  two 
membranes,  one  within  the  other,  having  very  transparent  jelly  in- 
terposed between  them.  But  in  process  of  time  the  innermost, 
which  is  called  the  amnion,  grows  so  much  faster  than  the  outer- 
most, called  the  chorion,  that  it  comes  in  contact  with  it,  or  at  least 
has  only  a  thin  layer  of  jelly  interposed. 

The  amnion  is  thin,  pellucid,  and  totally  without  the  appearance 
of  either  vessels  or  regular  fibres  ;  yet,  in  the  end  of  pregnancy,  it 
is  stronger  than  the  chorion  and  its  vascular  covering :  it  lines  the 
chorion,  covers  the  placenta,  and  mounts  up  on  the  naval  string, 
affording  a  coat  to  it  all  the  way  to  the  umbilicus,  where  it  termi- 
nates. 

The  sac,  formed  by  the  amnion,  is  filled  with  a  fluid,  which  ap- 
pears to  be  composed  chiefly  of  water,  with  a  very  little  earth,  al- 
bumen, and  saline  matter.  As  this  water  is  contained  within  the 
amnion,  it  has  received  the  name  of  liquor  amnii.  In  this  sac  the 
fetus  lies. 

The  quantity  of  water,  upon  an  average,  which  is  contained 
within  the  amnion,  at  the  full  time,  is  about  two  English  pints  ; 
but  sometimes  it  is  much  more,  and  at  other  times  scarcely  six 
ounces.  In  the  early  periods,  the  quantity  is  larger,  in  proportion 
to  the  size  of  the  uterus,  than  afterwards. 

The  chorion,  like  the  amnion,  is  thin  and  transparent,  adheres 
firmly  to  the  placenta,  and  covers  all  the  vessels  which  run  on  its 


192 

surface ;  but  it  does  not  dip  down  with  them  into  the  substance  of 
the  placenta.  The  ovum,  when  it  first  descends,  or  at  least  very- 
soon  afterwards,  has  the  chorion  every  where  covered  with  vessels, 
which  sprout  out  from  it.  These  form  a  covering  to  it,  which, 
from  its  appearance  has  been  called  the  shaggy  or  spongy  cho- 
rion. 


§  11.  UECIDUA. 

The  last  coat  to  be  described,  is  one  yielded  entirely  by  the 
uterus,  and  serves  to  connect  the  uterus  with  the  fcetal  vessels  of 
the  chorion.  This,  as  Harvey  observes,  is  not  a  covering  of  the 
foetus,  but  a  lining  of  the  uterus,  which  falls  off  alter  delivery  ; 
and  therefore  it  is  called  the  caducous  coat,  or  the  membrana 
decidua. 

The  illustrious  Haller  supposed,  that  this  was  formed  by  naked 
vessels  shooting  out  from  the  uterus.  Dr.  Hunter  imagined  that 
the  arteries  of  the  uterus  poured  out  coagulable  lymph,  which  was 
afterwards  changed  into  decidua.  His  brother,  Mr.  John  Hunter, 
attributed  its  origin  to  coagulated  blood,  which  formed  a  pulpy 
substance  on  the  inner  surface  of  the  uterus. 

Having  been  so  fortunate  as  to  meet  with  three  or  four  opportu- 
nities of  investigating  the  state  of  the  uterus,  within  a  month  after 
conception,  I  shall  describe  what  appears  to  me  to  be  the  structure 
of  the  decidua.  Very  speedily  after  impregnation,  and  always  be- 
fore the  embryo  enters  into  the  womb,  its  size  is  increased,  its 
fibres  are  softer  and  more  separated  from  each  other,  and  its  ves- 
sels very  much  enlarged.  On  cutting  it  up,  its  cavity  is  found  to  be 
considerably  broader  and  longer,  and  somewhat  wider  than  in  the 
unimpregnated  state ;  and  all  the  fundus  and  body  have  their  sur- 
face covered  with  a  dense  coat,  which  adheres  firmly  to  the  ute- 
rus. If  the  vessels  have  been  injected,  this  evidently  is  seen  to 
consist  of  two  different  substances,  namely,  vessels,  and  a  firm 
tough  gelatine.  It  seldom  happens  that  all  the  vessels  can  be 
equally  filled,  and  therefore  some  spots  are  redder  than  others. 
The  vessels  do  not  pass  on  to  the  surface  of  this  coat,  but  are  seen 


193 

shining  through  it.  They  proceed  directly  from  the  surface  of  the 
womb,  and  project  at  right  angles  to  the  plane  which  yields  them; 
they  are  intermixed  with  a  little  gelatine,  and  consist  of  both  arte- 
ries and  veins.  Over  their  extremities  is  spread  a  layer  of  gelati- 
nous matter,  which  very  early  is  observed  to  contain  fibres,  form- 
ing a  kind  of  net-work.  Thus  the  decidua  consists  of  two  layers, 
one  highly  vascular,  proceeding  directly  from  the  uterus;  the  other, 
which  is  most  probably  formed  by  these  vessels,  is  more  fibrous 
and  gelatinous;  and  when  this  is  removed,  the  primary  vessels,  or 
outer  layer,  may  be  seen  like  a  fine  efflorescence,  covering  the 
surface  of  the  uterus.  In  some  cases  the  decidua  extends  a  little 
into  the  fallopian  tubes ;  in  other  instances  it  does  not.  In  no  case 
does  the  cervix  form  decidua.  It  is  only  produced  by  the  fundus 
and  body  of  the  womb;  and  immediately  above  the  cervix,  the 
decidua  stretches  across,  so  as  to  form  a  circumscribed  bag  within 
the  uterus.  In  some  instances,  however,  1  have  observed  this  con- 
tinuation to  be  wanting,  although  the  parts  were  opened  with  care. 
In  all  other  circumstances,  these  uteri  resembled  those  where  the 
decidua  was  continued  across;  but,  perhaps,  notwithstanding  this, 
there  may  have  been  a  difference  of  two  or  three  days  in  the  pe- 
riod of  impregnation,  occasioning  this  variation.  In  every  case, 
the  decidua,  consisting  thus  of  two  layers,  is  completely  formed 
before  the  ovum  descends. 

When  the  embryo  passes  down  through  the  tube,  it  is  stopped, 
when  it  reaches  the  uterus,  by  the  inner  layer,  which  goes  across 
the  aperture  of  the  tube,  and  thus  would  be  prevented  from  falling 
into  the  cavity  of  the  uterus,  even  were  it  quite  loose  and  unat- 
tached. By  the  growth  of  the  embryo,  and  the  enlargement  of 
the  membranes,  this  layer  is  distended,  and  made  to  encroach 
upon  the  cavity  of  the  uterus,  or,  more  correctly  speaking,  it  grows 
with  the  ovum.  This  distention  or  growth  gradually  increases, 
until  at  last  the  whole  of  the  cavity  of  the  uterus  is  filled  up,  and 
the  protruded  portion  of  the  inner  layer  of  the  decidua  comes  in 
contact  with  that  portion  of  itself  which  remains  attached  to  the 
outer  layer.  We  find  then,  that  the  inner  layer  is  turned  down 
and  covers  the  chorion;  from  which  circumstances,  it  has  been 

2f, 


194 

called  the  reflected  decidua.(s)  In  Sir  E.  Home's  case,  he  says, 
the  tubes  were  quite  pervious,  that  is,  no  decidua  was  stretched 
across  them,  and  the  ovum  lay  at  the  cervix  uteri.  In  such  a  case, 
the  ovum  instead  of  growing  downwards  would  grow  upwards,  and 
carry  still  a  reflected  cast  of  decidua  with  it. 

Thus  we  see,  that  whenever  the  ovum  descends,  it  is  encircled 
by  a  vascular  covering  from  the  uterus,  which  unites,  in  every 
point,  with  those  shaggy  vessels  which  sprouted  from  the  chorion, 
and  which  made  what  was  called  the  spongy  chorion.  One  part 
of  these  vessels  forms  placenta,  and  the  rest  gradually  disappear, 
leaving  the  chorion  covered  by  the  decidua  reflexa.  This  oblite- 
ration begins  first  at  the  under  part  of  the  chorion. 


CHAP.  XVII. 

Of  Sterility. 

Sterility  depends  either  on  malformation,  or  imperfect  action 
of  the  organs  of  generation.  In  some  instances  the  ovaria  are 
wanting,  or  too  small ;  or  the  tubes  are  imperforated ;  or  the  uterus 
very  small.  In  these  cases  the  menses  generally  do  not  appear, 
the  breasts  are  flat,  the  external  organs  small,  or  they  partake  of 
the  male  structure,  and  the  sexual  desire  is  inconsiderable. 

In  a  great  majority  of  instances,  however,  the  organs  of  genera- 

(s)  By  others  it  is  thus  explained,  viz.  That  after  the  cavity  of  the  uterus  is 
completely  lined  with  the  secreted  decidua,  the  ovum  passes  into  it  from  the  fallo- 
pian tube,  and  in  passing  along  its  parietes,  involves  and  covers  itself  completely 
over  every  point  of  its  surface  with  a  coat  of  the  decidua,  which  at  that  period 
may  be  compared  to  a  coat  of  white  paint ;  as  the  ovum  increases  in  size,  the 
decidua  immediately  covering  it,  (called  decidua  reflexa)  ultimately  comes  into 
intimate  contact  with  that  portion  of  the  decidua,  which  continues  to  line  the 
cavity  of  the  uterus,  and  forms  apparently  but  one  membrane. 


195 

tion  seem  to  be  well  formed,  but  their  action  is  imperfect  or  disor- 
dered. The  menses  are  either  obstructed  or  sparing,  or  they  are 
profuse  or  too  frequent,  and  the  causes  of  these  morbid  conditions 
have  been  already  noticed. 

It  is  extremely  rare  for  a  woman  to  conceive,  who  does  not 
menstruate  regularly;  and,  on  the  contrary,  correct  menstruation 
generally  indicates  a  capability  of  impregnation  on  the  part  of  the 
woman. 

A  state  of  weakness  and  exhaustion  of  the  uterine  system,  occa- 
sioned by  frequent  and  promiscuous  intercourse  with  the  other 
sex,  is  another  very  common  cause  of  barrenness  in  women,  and 
hence  few  prostitutes  conceive. 

A  morbid  state  of  the  uterus  and  ovaria,  often  accompanied  with 
fluor  albus,  may  likewise  be  ranked  amongst  the  causes  of  sterility, 
and  this  is  known  by  its  proper  characters. 

Women  who  are  very  corpulent,  are  often  barren,  for  their  cor- 
pulence either  depends  upon  want  of  activity  of  the  ovaria,  spayed, 
or  castrated  animals  generally  becoming  fat,  or  it  exists  as  a  mark 
of  weakness  of  the  system. 

When  sterility  depends  upon  organic  disease,  we  have  it  seldom 
in  our  power  to  remove  it ;  but  when  there  is  no  mark  of  the  ex- 
istence of  such  a  state,  and  we  have  ground  to  suppose  that  it  is 
occasioned  by  debility,  or  imperfect  action  of  the  uterine  system, 
we  are  to  employ  such  means  as  are  supposed  capable  of  removing 
this,  either  by  operating  on  it  along  with  the  general  system  of  the 
body,  or  more  directly  on  the  uterus  itself.  Our  first  attention  must 
be  directed  to  menstruation,  as  the  state  of  that  function  is  our 
principal  directory  in  the  choice  of  the  class  of  medicines  to  be 
employed.  On  this  subject  I  must  refer  to  what  has  been  said  in 
chap.  xii.  We  will  also,  altogether  independently  of  the  state  of 
menstruation,  naturally  consider  the  condition  of  the  constitution 
and  habit  of  body,  with  regard  to  plethora,  irritability,  torpor,  or 
debility,  and  use  varied  and  persevering  means  for  rectifying  those 
states;  always,  however,  taking  care  that  we  do  not  injure  the 
constitution  in  seeking  for  a  remote  good.  In  the  majority  of  cases, 
weakness  of  uterine  action  is  the  cause,  and  the  remedies  are  sea- 
bathing and  tonics,  in  various  forms ;  general  stimulants,  such  as 


196 

Bath  waters,  mercury,  essential  oils,  nitrous  acid,  &c.  when  medi- 
cines of  this  description  are  not  contraindicated  by  the  state  of 
menstruation ;  local  stimulants,  which  act  more  directly  on  the 
uterus  or  its  vicinity,  as  the  semicupium,  cantharides,  balsam  of 
copaiba,  kc.  Of  all  these,  the  first  class  is  the  safest,  and  the 
most  frequently  useful.  The  ancients  employed  medicated  pes- 
saries, which  have  long  fallen  into  disrepute,  rather,  perhaps,  from 
the  absurdity  of  their  ingredients,  than  from  any  argument  re- 
specting the  inefficacy  of  gentle  stimulants  acting  on  the  vagina 
and  womb. 

A  temporary  separation  from  the  husband  is  of  service,  espe- 
cially when  the  menses  are  profuse,  and,  in  most  cases,  frequent 
intercourse  should  be  avoided. 

Should  a  woman,  who  has  been  for  some  years  barren,  con- 
ceive, she  must  be  very  careful  during  gestation,  for  abortion  is 
readily  excited. 

In  some  cases,  the  uterine  system  is  capable  of  being  acted  on 
by  the  semen  of  one  person,  but  not  of  anotheP. 


CHAP.  XVIII. 

Of  Extra-uterine  Pregnancy. 
§  1.  SYxMPTOMS,  PROGRESS,  AND  SPECIES. 

It  sometimes  happens  that  the  ovum  does  not  pass  down  into 
the  womb,  but  is  retained  in  the  ovarium,  or  stops  in  the  tube,  or 
is  deposited  among  the  bowels.  Of  all  these  species  of  extra-ute- 
rine pregnancy,  the  tubal  is  the  most  frequent. 

The  symptoms  of  extra-uterine  pregnancy  are  not,  at  first,  very 
definite  ;  but  generally,  the  usual  sympathetic  effects  of  pregnancy, 
or  the  diseases  of  gestation,  are  more  distressing  than  if  the  foetus 


197 

were  contained  in  utcro,  nor  do  they  cease  so  early.  In  some 
cases,  they  even  increase  in  violence,  as  pregnancy  advances.* 

The  symptoms,  though  often  more  violent,  are,  however,  simi- 
lar in  kind  to  those  of  common  pregnancy.  The  belly  swells,  the 
uterus  itself  enlarges,  and  may  be  felt  to  be  heavy ;  but  after  some 
time,  it  does  not  correspond  in  its  size,  and  in  the  state  of  its  cer- 
vix, to  the  supposed  period  of  gestation,  or  may  return  to  the  un- 
impregnated  size.f  The  menses  are  often  obstructed,  though' in 
some  cases  they  have  continued  to  appear  for  two  or  three  months. 
The  breasts  enlarge,  the  morning  sickness  takes  place  about  the 
usual  period,J  and  the  child  quickens  at  the  proper  time,  but  it  is 
felt  chiefly  upon  one  side.  An  obstruction  to  the  free  passage  of 
urine  is  sometimes  produced  till  the  sac  rise  out  of  the  pelvis. 

Occasionally  in  the  early  stage  of  pregnancy,  pains^  resembling 
those  of  colic,  are  felt,  and  these  are  often  so  severe  as  to  excite 
syncope,||  or  convulsions  ;1T  and  it  has  happened,  that  during  these 
pains,  the  tube  or  ovarium  has  burst,  and  the  person  died,  owing 


*  Vide  Paper  by  Dr.  Garthshore,  Lond.  Med.  Journ.  Vol.  VIII.  p.  344. 

f  Vide  Mr.  Tucker's  case,  Med.  and  Fins.  Journ.  xxix.  448. 

t  In  Dr.  Clark's  case  the  morning  sickness,  and  other  signs  of  pregnancy,  ap- 
peared very  regularly.  At  the  end  of  nine  months,  attempts  were  made  to  ex- 
pel the  foetus.  These  were  followed  by  inflammation  and  decline  of  health. 
Then  suppuration  took  place,  and  the  patient  sunk.  Transactions  of  a  Society, 
&c.  Vol.  II.  p.  1.  In  Mr.  Mainwaring's  case,  in  the  same  work,  p.  287,  the  pa- 
tient suffered  much  from  morning  sickness,  and  pain  at  the  groins. 

§  In  the  Journal  de  Scavans  for  1756,  we  are  told  of  a  woman  at  Louvain,  who 
at  first  had  so  dreadful  pain  when  she  went  to  stool,  that  she  thought  her  bowels 
were  coming  out. — In  Pouteau's  case  the  woman  suffered  great  pain  till  after  the 
second  month.     Melanges,  p.  333. 

||  Bianchi  mentions  a  case,  in  which,  in  the  first  months,  the  woman  complain- 
ed of  great  pain  in  the  lower  belly,  with  nausea,  and  fainting  fits.  The  motion 
of  the  child  ceased  in  the  fifth  month,  and  then  milk  was  secreted.  De  Nat.  in 
Hum.  Corp.  Vitioso  Morbosoque  Gener.  p.  166. — In  Dr.  Mounsey'scase,  the  pain, 
vomiting,  and  fainting  fits,  continued  till  the  woman  quickened.  Phil.  Trans.  Vol. 
XLV.  p.  131. —  In  Dr.  Fern's  case,  the  person  complained  of  great  pain  till  the 
third  month  ;  and  from  that  period  till  the  eighth  month,  was  subject  to  convul- 
sions and  syncope.     Phil.  Trans.  Vol.  XXI.  p.  121. 

1  Vide  Dr.  Fern's  case,  and  a  case  by  Mr.  Jacob,  in  Lond.  Med.  Jour.  Vol.  VIII. 
p.  147 


198 

to  the  internal  hemorrhage.*  When  these  pains  either  do  not  oc- 
cur, or  are  removed,  or  the  patient  survives  the  rupture  of  the  sac, 
we  generally  find,  that  at  the  end  of  eight,  nine,  or  ten  months  from 
the  commencement  of  gestation,  appearances  of  labourf  take  place ; 
the  woman  suffers  much  from  pain,  and  there  may  be  a  sanguine- 
ous discharge  from  the  uterus.  The  pains  go  off  more  or  less 
gradually,!  the  motion  of  the  child  ceases,  and  milk  is  secreted.^ 
fS  a  few  instances,  very  little  farmer  inconvenience  is  felt,  the 
tumour  of  the  belly  remaining  for  many  years,  and  the  child 
being  converted  into  a  substance  resembling  the  gras  des  cimetieres> 
whilst  the  sac  which  contains  it  becomes  indurated.  More  fre- 
quently, however,  considerable  irritation  is  produced,  ||  with  nau- 
sea, loss  of  appetite,  frequent  vomiting,  chills,  difficulty  of  breath- 
ing, and  great  debility ;  inflammatory  symptoms  supervene,  and 
hectic  takes  place.  The  sac  adheres  to  the  peritoneum,  or  intes- 
tines ;  and  after  an  uncertain  period,  varying  from  a  few  weeks  or 
months  to  several  years,  it  either  opens  externally,  or  communi- 


*  In  Mr.  Langstaff's  case,  the  patient  felt  violent  pains  in  the  lower  belly,  sick- 
ness, and  faintness,  and  died  in  seven  hours  after  being  taken  ill.  Two  quarts  of 
blood  were  found  effused  into  the  pelvis,  and  abdomen,  and  a  fatus,  with  its 
membranes,  was  found,  apparently  about  eight  weeks  old.  The  right  fallopian 
tube  was  as  large  as  a  hen's  egg,  and  had  burst  in  two  places.  The  uterus  was 
very  vascular,  and  contained  jelly,  but  it  is  said  had  no  decidua;  and  the  cervix 
was  not  shut  up  by  mucus.  The  tube  was  obliterated  at  the  uterine  extremity, 
which  probably  was  the  cause  of  the  evil.  Med.  Chir.  Trans.  Vol.  VII.  p.  437. 
Sabatier  mentions  two  instances  of  ovarian  pregnancy,  where  the  patient  died 
quickly  after  pain  and  fainting.     Med.  Operat.  Tom.  I.  p.  343. 

-j-  In  Dr.  Perfect's  case,  no  labour  pains  came  on,  but  the  motion  of  the  child 
ceased  at  the  end  of  nine  months.  The  abdomen  neither  increased  nor  diminish- 
ed in  size  for  two  years  and  seven  weeks  ;  but  she  was  afflicted  with  constant 
pain  in  the  hypogastric  region,  attended  with  fever,  and  finally  sunk  under  maras- 
mus.    Cases  in  Midwifery,  Vol.  II.  p.  164. 

+  In  Mr.  Bell's  case,  the  pains  continued,  though  gradually  abating,  for  three 
weeks.     Med.  Comment.  Vol.  II.  p.  72. 

§  In  Mr.  Bell's  case,  milk  continued  to  be  secreted  for  several  years.  In  Mr. 
Turnbull's  case,  a  fluid  was  secreted,  rather  like  pus  than  milk. 

||  In  the  case  of  a  female  mulatto,  the  outlines  of  which  I  was  favoured  with  by 
Dr.  Chisholm,  the  pain  was  so  great  that  it  could  not  be  allayed  by  the  strongest 
opiates.    It  ended  fatally. 


199 

c'ates  with  the  abdominal  viscera.  Very  fetid  matter,  together 
With  putrid  flesh,  bones,  and  coagula,  are  discharged  through  the 
abdominal  integuments*  or  by  the  rectum,f  vagina,f  or  bladder.^ 
Sometimes,  even  an  entire  fetus  has  been  brought  away  from  the 
umbilicus, ||  or  by  the  rectum.1T     It  is  worthy  of  notice,  that  the 

*  This  termination  is  noticed  so  long  ago  as  by  Albucasis,  lib.  U.  c.  76.  In  the 
Paduan  Commentaries,  there  is  related  a  case,  where  the  abdominal  parietes 
opened  by  gangrene,  which  is  also  said  to  have  affected  the  uterus,  and  the  child 
was  then  expelled,  and  the  patient  recovered. 

f  Vide  cases  by  Langius,  in  his  Epistolx,  Tom.  II.  p.  670.  Tulpius,  Opera,  lib. 
IV.  c.  39.  p.  358. — Pouteau  in  his  Melanges,  p.  373. — Mr.  Shiever,  in  Phil.  Trans. 
No.  303.  p.  172.— Winthrop.  Phil.  Trans.  Vol.  XLIII.  p.  304.  and  Simon,  p.  529. 
— Lindestaple,  Vol.  XLIV.  p.  617.  Morley,  Vol.  XIX.  p.  486.  Gordon,  in  Med. 
Comment.  Vol.  XVIII.  p.  323.  Cammel,  in  Lond.  Med.  Jour.  Vol.  V.  p.  96.  Case 
by  M.Bergeret,  in  the  Recueil  Periodique,  Tom.  XIV.  p.  289. 

t  Vide  Marcel.  Donatus,  De  Med.  Hist.  Mirab.  lib.  IV.  c.  22. — Horstii  Opera, 
Tom.  II.  p.  536.  In  this  case,  the  fetus  was  discharged  both  by  the  vagina  and 
rectum. — Benevoli,  in  his  Dissert,  p.  104,  gives  an  instance  where  the  greater 
part  of  the  child  was  expelled  by  the  vagina,  but  the  woman  died  before  the  pro- 
cess was  completed. — Mr.  Smith's  case  in  Med.  Comment.  Vol.  V.  p.  314. — In  Mr. 
Colman's  case,  pains  came  on,  and  the  head  was  felt  in  the  pelvis  at  the  time  of 
her  reckoning,  and  long  afterwards,  but  the  os  uteri  could  not  be  perceived.  In 
some  time,  hectic  fever,  with  diarrhoea  and  sore  mouth,  appeared.  Six  months 
after  her  attempts  at  labour,  an  opening  was  felt  in  the  vagina,  but  very  unlike  the 
os  uteri.  The  hand  was  introduced,  and  a  putrid  child  was  extracted.  Some 
faeces  continued  to  come  by  the  wound,  but  at  last  she  got  well.  Med.  and  Phys. 
Jour.  Vol.  II.  p.  262. — See  also  Camper's  case,  in  his  Demonst.  Anat.  Path.  lib.  II. 
p.  16.  and  Dr.  Fothergill's  case,  in  Mem.  of  Med.  Society,  Vol.  VI.  p.  107. 

§  Vide  Stalpart  Van  der  Wiel,  Opera,  Tom.  I.  p.  305.  In  this  case,  bones  came 
away  with  the  urine. — In  the  case  of  Ronseus,  the  child  was  discharged  partly  by 
the  bladder,  but  chiefly  by  the  anus.  Epist.  Med. — A  similar  instance  is  related 
by  Morlanne,  the  extraneous  matter  forming  a  nucleus  for  a  calculus.  By  an 
operation  similar  to  that  of  lithotomy,  two  stones  and  five  portions  of  cranial 
bones  were  extracted.  Recueil  Period.  Tom.  XIII.  p.  70. — In  Prof.  Josephi's 
case,  the  child  was  found  altogether  in  the  bladder.  Med.  and  Phys.  Jour.  Vol. 
XIV.  p.  519. 

||  Vide  case  of  Mrs.  Stag,  in  Lond.  Med.  Obs.  and  Inquiries,  Vol.  II.  p.  369  , 
and  cases  by  Mr.  Jocob,  Dr.  Maclarty,  and  others. 

K  In  Mr.  Gifford's  case,  the  child  was  expelled  entire  by  the  anus,  and  even 
the  cord  was  found  hanging  out  of  the  intestine.     Phil.  Trans.  Vol.  XXXVI.  ]■• 
435. — See  also  Mr.  Goodsir's  case,  in  Annals  of  Medicine,  Vol.  VII.  p.  412. —  B1 
Albers  has  a  similar  case. 


200 

placenta,  in  this  process',  always  is  ultimately  destroyed,*  and  dis- 
charged among  the  putrid  fluid.  Often  time  is  not  allowed  for 
this  process  to  be  accomplished,  but  the  person  dies  at  an  early 
period. 

Thus  it  appears,  that  there  are  different  terminations  of  the  ex- 
tra-uterine pregnancy.  The  sac  may  burst,  and  the  person  die 
speedily  of  hemorrhage  ;f  or  the  child  may  escape  into  the  abdo- 
men, and  be  enclosed  in  a  kind  of  cyst  of  lymph  ;J  or  the  sac  may 
remain  entire,  the  child  being  retained  many  years,^  and  the  parts 
become  hard  j  notwithstanding  this,  the  menses  may  return,  and 


*  In  Dx*.  M'Knight's  case,  although  the  cesarean  operation  was  performed  be- 
fore any  bad  effects  were  produced  on  the  health,  no  part  of  the  placenta  could 
be  found. 

f  In  Dr.  Clark's  case,  the  tube  burst  in  the  second  month,  and  the  woman  died 
from  loss  of  blood.  Transactions  of  a  Society,  Vol.  I.  p.  216. — Vide  case  by 
Duverney,  in  his  works,  Tom.  II.  p.  353.  and  by  M.  Littre  in  the  Memoirs  of 
the  Acad,  of  Sciences,  for  1702,  and  by  Riolan,  in  his  works.  See  also  Med. 
Comment.  Vol.  I.  p.  429. — In  Mr.  T.  Blizard's  case,  rupture  took  place  at  a  very 
early  period,  for  the  woman  had  miscarried  only  five  weeks  previous  to  this  event. 
Vide  Edin.  Phil.  Trans.  Vol.  V.  p.  189.— Mr.  Tucker's  case,  Med.  and  Ph}s.  Jour- 
nal, XXIX.  448. 

*  Vide  a  case  by  La  Croix,  in  La  Med.  Eclaree,  Tome  IV.  p.  349. 

§  1  have  known  the  foetus  retained  for  twenty  years,  and  there  are  some  instan- 
ces, where  it  has  been  retained  for  thirty,  forty,  or  fifty  years.  Mrs.  Ruff",  whose 
case  is  related  in  the  Med.  and  Phys.  Jour,  for  May  1800,  carried  the  child  fifty 
years.  Middleton's  patient  carried  it  sixteen  years.  Phil.  Trans.  Vol.  XLIV.  p. 
617.  Mounsey's  thirteen  years,  Vol.  XLV.  p.  121.  Steigertahl's  forty-six  years, 
Vol.  XXXI.  p.  126.  Broomfield's  nine  years,  Vol.  XLI.  p.  696.  Sir  P.  Skippon's 
patient  discharged  it  by  suppuration  at  the  groin,  after  retaining  it  twenty  years, 
Vol.  XXIV.  p.  2070.  See  also  cases  by  M.  Grivel,  in  Edin.  Med.  Jour.  Vol.  11  p. 
19,  and  Dr.  Caldwell,  p.  22.  Sometimes  no  attempt  is  made  to  expel,  but  the 
foetus  is  converted  into  a  substance,  which  Fourcroy  finds  to  resemble  the  gras 
des  cimetieres.  System,  Tom.  X.  p.  83.  Sandifoxt  i^elates  a  case,  where,  after 
attempts  at  laboui1,  no  further  inconvenience  was  sustained,  but  the  child  was 
found  after  twenty-two  years  to  be  indurated.  Observationes,  lib.  II.  p.  36. 
He  quotes  Nebel  for  a  case,  where  it  was  retained  fifty-four  years.  Cheselden 
found  it  converted  into  earthy  matter.  The  late  Mr.  Hamilton  of  this  place  had 
a  preparation  of  a  foetus,  covered  with  calcareous  matter,  which  was  retained  32 
years.  This  woman  had  pains  at  the  end  of  nine  months,  after  which  the  belly 
decreased  in  size.- 


201 

the  woman  conceive  again.*  But  the  most  frequent  termination  is 
that  of  inflammation  ending  in  abscess,  attended  with  fever  and 
pain,  under  which  the  patient  either  sinks,  or  the  foetus  is  expelled 
in  pieces,  and  the  cure  is  slowly  accomplished.  From  a  review  of 
cases  it  appears,  that  a  majority  ultimately  recover,  or  get  the  bet- 
ter of  the  immediate  injury  :  of  the  rest,  some  have  sunk  speedily, 
either  from  hemorrhage  or  inflammation,  or  exhaustion  produced 
by  ineffectual  attempts  to  expel  the  child ;  or  more  slowly  from 
hectic  fever ;  or  in  consequence  of  some  other  disease  being 
called  into  action,  by  the  violence  which  the  constitution  has  sus- 
tained. 

In  some  cases  the  sac  soon  rises  quite  out  of  the  pelvis.  In 
others,  it  remains  longer,  and  falls  down  between  the  rectum  and 
vagina,  forming  a  tumour,  accompanied  with  symptoms  of  retro- 
version of  the  uterus. f  In  such  cases,  the  sac  inflames,  and  bursts 
into  the  rectum  or  vagina.  Dr.  MerrimanJ  is  of  opinion,  that  all 
these  cases  are  instances  of  retroverted  uterus,  and  not  of  extra- 
uterine pregnancy ;  but,  for  the  present,  this  must  rest  entirely  on 

*  In  the  5th  Vol.  of  the  Edin.  Med.  Essays,  there  is  related  a  case  in  which  the 
patient  seemed  to  have  a  second  extra-uterine  pregnancy  before  she  got  quit  of 
the  first. — See  also  Primrose  de  Morb.  Mul.  p.  326. — Mr.  Hope,  in  the  6th  Vol. 
of  the  Med.  and  Phys.  Jour.  p.  360,  details  a  case,  where  the  woman  in  the 
seventh  month  of  pregnancy  had  pains,  which  continued  for  three  weeks,  and 
then  went  off",  leaving  a  hard  tumour  on  the  left  side,  which  was  somewhat  pain- 
ful ;  she  then  had  another  pregnancy,  and  a  fortnight  after  delivery,  began,  after 
taking  a  laxative,  to  vomit,  and  continued  to  do  so,  ultimately  throwing  up  fecu- 
lent matter.  The  case  ended  fatally.— See  also,  Turk,  in  Haller,  Disp.  Chir. 
IV.  793. 

f  Vide  Mr.  Mainwaring's  case,  in  Trans,  of  a  Society,  &c.  Vol.  II.  p.  287.  In 
Mr.  White's  case,  related  in  Med.  Comment.  Vol.  XX.  p.  254,  Uie  symptoms 
vere  very  like  those  of  retroversion,  and  the  case  was  only  distinguished  by  the 
result.  In  Mr.  Cammel's  case,  there  was  not  only  a  tumour  betwixt  the  vagina 
and  rectum,  but  the  os  uteri  was  turned  upward  and  forward.  Lond.  Med.  Jour. 
Vol.  V.  p.  96.  Mr.  Kelson's  case  very  much  resembled  retroversion,  for  in  the 
tenth  week  both  the  urine  and  stools  were  obstructed.  In  about  a  fortnight, 
the  impediment  was  suddenly  removed,  and  the  uterus  felt  in  situ.  She  conti- 
nued well  to  the  ninth  month,  when  labour  ineffectually  came  on;  but  in  pro- 
cess of  time  the  child  was  discharged  by  the  anus.  Med.  and  Phys.  Jour.  Vol, 
XI.  p.  293. 

-Vide  lJisSert\on  RetrOTeTsion,  &c.  1810. 

r? 


202 

supposition.  The  mere  circumstance  of  tho  pregnancy  being  com- 
plicated with  suppression  of  urine,  or  tumour  at  the  back  part  of 
the  pelvis,  is  no  proof;  as  both  of  these  may  arise  from  the  pres- 
sure of  the  sac  on  the  pelvis. 

Sometimes,  when  parturient  efforts  are  made,  the  head  descends 
into  the  pelvis,  though  it  was  not  there  before ;  but  either  no  os 
uteri  can  be  felt,  or  it  is  felt  directed  to  the  pubis,  and  it  is  not 
affected  by  the  pains.(/!) 

It  is  curious  to  observe,  that  generally  the  uterus  enlarges  some- 
what,* and,  in  most  instances,  I  imagine,  deciduaf  is  formed.  In 
a  remarkable  case,  related  by  the  ingenious  Mr.  Hay,J  of  Leeds, 
the  placenta  was  formed  in  the  uterus,  while  the  foetus  lay  in  the 
tube. 

Tubal  pregnancy  sometimes  does  not  proceed  farther  than  the 
second  month,  the  tube  bursting  at  that  time ;  or,  to  speak  more 
correctly,  I  believe  the  tube  slowly  inflames,  and  sloughing  takes 
place.  In  many  instances,  however,  the  tube  goes  on  enlarging 
for  nine  months,  and  acquires  a  size  nearly  equal  to  that  of  the 

(?)  It  is  very  probable  that  some  of  these  cases  have  in  reality  originated  from 
retroversions  of  the  uterus,  which,  as  Merriman  has  proved,  may  even  continue 
partially  in  that  state  until  the  full  period  of  utero-gestation.  This  subject  shall 
be  more  fully  explained,  when  retroversion  of  the  uterus  comes  to  be  treated  of. 
In  the  meantime  the  student  is  referred  to  a  review  of  Dr.  Merriman's  Work, 
in  the  Eclectic  Repertory,  Vol.  I.  p.  338. 

*  Bcchmer  long  ago  observed  this;  and  Dr.  Baillie,  in  the  79th  Vol.  of  the 
Phil.  Trans,  mentions,  that  Dr.  Hunter  had  a  preparation  of  tubal  pregnancy,  in 
which  the  uterus  was  found  enlarged  to  double  its  natural  size,  and  containing 
decidua.  He  also  states,  that  in  an  ovarian  case,  the  uterus  was  enlarged,  thick, 
and  spongy,  and  its  vessels  enlarged.  Dr.  Clarke  found  the  uterus,  in  the  second 
month  of  an  extra-uterine  pregnancy,  exactly  of  the  same  size  as  if  the  embryo 
had  been  lodged  within  it.  The  decidua  was  formed,  and  the  cervix-  filled  with 
gelatinous  matter.  Transactions  of  a  Society,  Vol.  I.  p.  216.  See  also  a  case  by 
Saviard,  in  Phil.  Trans.  No.  222.  p.  314.  A  case  similar  to  Dr.  Clarke's  is  related 
by  Mr.  T.  Pdizard,  in  the  Edin.  Phil.  Trans.  Vol.  V.  p.  189.  See*also  Annals  of 
Med.  Vol.  111.  p.  379. 

J  In  Mr.  Houston's  case,  the  cervix  was  so  closed  up  that  it  would  not  admit  a 
probe.  Phil,.  Trans.  Vol.  XXXII.  p.  387.  The  decidua  would  appear  sometimes 
to  enlarge,  and  form  u  mass  like  placenta,  which  in  Mr.  TurnbulPs  case  was  ex- 
pelled with  hemorrhage.     Mem.  of  Med.  Society,  Vol.  III.  p.  176. 

i  Vide  Med.  Obs.  and  Inq.  Vol.  III.  p.  341. 


203 

gravid  uterus,  at  the  same  stage  of  gestation.*  The  placenta  dif- 
fers from  a  uterine  placenta  in  being  much  thinner  and  more  ex- 
tended. External  examination  discovers  little  difference,  at  the 
full  time,  between  this  and  common  pregnancy. 

Ovarianf  is  much  more  rare  than  tubal  pregnancy,  and  it  is  sel- 
dom that  the  ovarium  acquires  a  great  size.  It  either  bursts  ear- 
ly!, or  inflammation  and  abscess  take  place ;  or  the  foetus  dies, 
and  is  converted  into  a  confused  mass  ;  or  it  excites  dropsy  of  the 
ovarium.^  The  ovarian  pregnancy,  until  inflammation  has  taken 
place,  produces  a  circumscribed  moveable  tumour,  like  dropsy  of 
the  ovarium. 

In  ventral  pregnancy,  the  most  rare  of  the  three  species,  the  mo- 
tions of  the  child  are  felt  more  freely,  and  its  shape  is  readily  dis- 
tinguished through  the  abdominal  integuments.  The  expulsive 
efforts  come  on  as  usual,  and  the  head  of  the  child  is  sometimes 
forced  into  the  pelvis.  It  dies,  and  the  usual  process  for  its  remo- 
val is  carried  on,  if  the  woman  do  not  sink  immediately  under  the 
irritation.     The  placenta  is  found  attached  to  the  mesentery  or  in- 


*  Among  many  other  cares  in  proof  of  this,  I  may  refer  to  one  very  accurately 
detailed  by  Dr.  Clarke,  in  Trans,  of  a  Society,  <kc.  Vol.  II.  p.  1. 

j  In  a  case  related  by  Varocquier,  the  ovarium  did  not  acquire  a  larger  size 
than  an  egg.  The  woman  died,  after  suffering  violent  pain  in  the  left  side,  low 
down.  The  viscera  were  slightly  inflamed.  Mem.  de  l'Acad.  de  Sciences,  lore. 
CXIII.  p.  76.  In  the  case  by  L'Eveille,  the  foetus  was  apparently  betwixt  three 
and  four  months  old.  Rapport  de  la  Societe  Philomatique,  Tom.  I.  p.  146.  See 
also  a  case  in  the  Recueil  Period.  Tom.  XIII.  p.  63 ;  and  in  the  ltecueil  des 
Actesde  la  Societe  de  Lyon. 

I  Vide  Chambon,  Malad.  de  la  Grosscsse,  Tom.  II.  p.  373.  Case  by  St.  Mau- 
rice, in  Phil.  Trans.  No.  150,  p.  285.  In  the  case  related  by  La  Rocque,  the  ova- 
rium was  found  ruptured,  and  the  abdomen  full  of  blood.  Journ.  de  Med.  1683. 
Bochmer  found  the  ovarium  ruptured,  and  the  foetus  half  expelled.  Obs.  Anat. 
fasc.  prinu  Dr.  Forrester's  patient,  after  violent  colic  pains,  voided  blood  by 
the  anus.  The  hemorrhage  and  fainting  fits  proved  fatal.  The  foetus  was  found 
in  the  ovarium.    Annals  of  Medicine,  Vol.  III.  p.  379. . 

§  Vide  Rcrderer,  Elemens,  c.  15.  §  758.  In  Mr.  Dumas's  case,  a  fluid  like 
chocolate  was  drawn  oft*  by  tapping,  which  was  twice  performed.  The  ovarium 
contained  hair,  bones,  &c.  La  Med.  Eclaire'e,  Tom.  IV.  p.  65.  Mr.  Bell's  tubal 
case  excited  ascites. 


204 

testines.*  It  has  been  supposed,  that  the  examples  of  this  variety 
are  all  in  reality  instances  of  ruptured  uteri  ;  but  this  is  not  sup- 
ported by  satisfactory  proof.  At  the  same  time,  I  have  no  doubt 
that  many  of  them  are. 

§  2.  TREATMENT. 

In  the  treatment  of  extra-uterine  pregnancy,  much  must  depend 
on  the  circumstances  of  the  case.  In  the  early  stage,  if  the  sac  be 
lodged  in  the  pelvis,  we  must  procure  stools,  and  have  the  bladder 
regularly  emptied,  as  in  cases  of  retroverted  uterus.  Attacks  of 
pain,  during  the  enlargement  of  the  tube,  require  blood-letting  and 
anodynes,  laxatives,  and  fomentations.  The  same  remedies  are 
indicated  when  convulsions  take  place.  Ovarian  requires  a  simi- 
lar management  with  tubal  pregnancy,  except  that  if  it  be  compli- 
cated with  dropsy,  relief  may  be  obtained  by  tapping. 

When  expulsive  efforts  are  made,  and  the  head  is  felt  through 
the  vagina,  and  the  nature  of  the  case  distinctly  ascertained,  it  may 
be  supposed,  and  some  recorded  cases  would  seem  to  justify  the 
supposition,  that  much  suffering  may  be  avoided,  by  making  an 
incision  through  the  vagina,  and  delivering  the  child  ;  but,  as  yet, 
experience  has  not  fully  ascertained  the  utility  of  this  practice,  f 

•  Vide  Dr.  Kelly's  case,  in  Med.  Obs.  and  Inquiries,  Vol.  III.  p.  44.  In  Mr. 
Clarke's  case,  the  placenta  was  attached  to  the  kidneys  and  intestines,  Mem.  of 
Med.  Society,  Vol.  III.  p.  179.  In  the  Mem.  of  the  Acad,  of  Sciences,  there  is 
a  case  related,  where  the  placenta  adhered  to  the  lumbar  vertebrae.  In  the  his- 
tory  by  La  Coste,  it  was  placed  under  the  stomach  and  colon.  Vide  (Euvres  de 
Duverney,  Tom.  II.  p.  363.  In  Mr.  Turnbull's  case,  it  was  very  thin,  and  adher- 
ed to  the  intestines.  Mem.  of  Med.  Society,  Vol.  III.  p.  176.  A  case  of  ventral 
pregnancy,  complicated  with  hernia,  is  related  by  M.  Martin  in  the  Recueil  des 
Actes  de  la  Societe  de  Sante  de  Lyon.  Courtial  found  it  adhering  to  the  sto- 
mach and  colon. 

|  In  a  case,  probably  of  this  kind,  related  by  Lauverjat,  and  quoted  by  Sabatier, 
the  child  was  extracted  by  an  incision  through  the  vagina,  and  the  woman  reco- 
vered. De  la  Med.  <  >per.  Tome  I.  p.  136.  A  similar  case  is  to  be  met  with  in 
the  Journ.  des.  Spavans,  1722.  A  very  interesting  case  is  related  by  Delisle,  in 
the  Bulletin  de  la  Societe  Med.  d'Emulation,  for  May  and  June,  1818  ;  where  the 
child  was  extracted  alive,  by  an  incision  through  the  vagina.  The  mother  died  in 
a  quarter  of  an  hour,  and  the  child  half  an  hour  after  her.  It  has,  in  one  instance, 
however,  been  extracted  thus,  with  success  to  both  parties. 


205 

It  has  been  proposed,  in  these  and  other  circumstances,  to  perform 
the  caesarean  operation,*  in  the  usual  manner,  upon  the  accession 
of  labour;  but  there  is  not  only  great  danger  from  the  wound,  but 
likewise  from  the  management  of  the  placenta,  which,  if  removed, 
may  cause  hemorrhage,  especially  in  ventral  pregnancy,  and,  if 
left  behind,  may  produce  bad  effects.  The  last,  however,  is  the 
safest  alternative. 

The  result  of  the  numerous  cases  upon  record  will  certainly  jus- 
tify, to  the  fullest  extent,  our  trusting  to  the  powers  of  nature, 
rather  than  to  the  knife  of  the  surgeon.  If  any  exception  is  to  be 
made  to  this  rule,  it  is  in  those  cases  where  the  child  is  distinctly 
felt  through  the  vagina,  and  can  be  extracted  by  an  incision  made 
there.  Allaying  pain  and  irritation  in  the  first  instance,  by  blood- 
letting, anodynes,  and  fomentations ;  and  avoiding,  during  all  the 
inflammatory  stage,  stimulants  and  motion,  whilst,  by  suitable 
means,  we  palliate  any  particular  symptom,  constitute  the  sum  of 
our  practice. 

A  tendency  to  suppuration  is  to  be  encouraged,  by  poultices : 
and  the  tumour,  when  it  points  externally,  is  either  to  be  opened, 
or  to  be  left  to  burst  spontaneously,  according  to  the  sufferings  of 
the  patient,  and  the  exigencies  of  the  case.f     The  passage  of  the 

*  M.  Colomb.  performed  the  caesarean  operation,  but  it  ended  fatally.  Recueil 
des  Actes  de  la  Societe  de  Lyon.  Osiander  has  also  failed. 
1.  f  Dr.  Maclartv  relates  the  case  of  a  negre.ss,  where  the  breech  of  the  child  pro- 
truded through  an  ulcer,  at  the  lower  part  of  the  abdominal  tumour,  and  the  arm 
at  the  upper  part  of  the  tumour.  The  intermediate  portion  of  skin  was  divided, 
and  the  foetus  extracted.  The  head  of  the  child  stuck  firmly,  but  was  brought 
out  with  the  forceps.  There  was  no  placenta,  but  putrid  matter  was  discharged 
with  the  child.  The  woman  recovered.  Med.  Comment.  Vol.  XVII.  p.  481. 
Another  case  is  related  by  Duverney,  where  the  child  was  extracted  from  the 
groin  ;  and  this  is  one  of  the  rare  instances  where  the  placenta  was  not  destroyed. 
It  was  extracted  with  the  child.  CEuvres,  Tom.  11.  p.  357.  Cyprianus  gives  an 
instance  of  the  child  being  removed,  after  having  been  retained  twenty  one 
months.  Histor.  Fcetus  Hum.  Salva  Matre  ex  Tuba  Excisi.  Mr.  Brodie  enlarged 
the  navel  with  a  lancet.  Phil.  Trans.  Vol.  XIX.  p.  580.  See  also  Mr.  Baynham's 
case,  in  Med.  Facts,  Vol.  I.  p.  73.  In  Mr.  Bell's  case  an  incision,  four  inches  in 
length,  was  made,  and  the  bones  of  two  children  extracted.  Med.  Comment. 
Vol.  II.  p.  72.  Dr.  Haighton  relates  an  interesting  case,  where  some  bones  were 
discharged  by  the  vagina,  but  the  tumour  also  pointed  above  the  pubis,  and 


20(5 

bones,  and  different  parts  of  the  foetus,  may  often  be  assisted  :  and 
the  strength  is  to  be  supported  under  the  hectic  which  accom- 
panies die  process.  After  the  abscess  closes,  great  care  is  still 
necessary,  for,  by  fatigue  or  exertion,  it  may  be  renewed,  and 
prove  fatal.* 

When  no  process  is  begun  for  removing  the  foetus,  but  it  is  re- 
tained and  indurated,  our  practice  is  confined  to  the  palliation  of 
£iich  particular  symptoms  as  occur. 


CHAP.  XIX. 

Of  the  Signs  of  Pregnancy. 

Some  women  feel,  immediately  after  conception,  a  particular 
sensation,  which  apprizes  them  of  their  situation ;  but  such  in- 
stances are  not  frequent ;  and,  generally,  the  first  circumstances 
which  lead  a  woman  to  suppose  herself  pregnant,  are  the  suppres- 
sion of  the  menses,  and  an  irritable,  or  dyspeptic  state  of  the 

through  this  one  of  the  ribs  appeared.  The  practitioner  made  an  incision,  but 
so  great  hemorrhage  came  on,  that  he  was  obliged  to  apply  a  bandage  till  nex£ 
day,  when  he  extracted  the  bones.  The  woman  recovered.  Med.  Records,  p.  260. 
Dr.  M'Knight  performed  the  operation  in  the  twenty -second  month,  although 
the  woman  enjoyed  tolerable  health ;  very  dangerous  symptoms  supervened, 
but  the  woman,  who  certainly  was  brought  into  a  very  hazardous  state  by  the 
premature  operation,  did  recover.  No  placenta  was  found.  Mem.  of  Med.  So- 
ciety, Vol.  IV.  p.  342. 

*  In  Dr.  Morley's  case,  this  happened  two  years  after  the  original  abscess  had 
healed.  Phil.  Trans.  Vol.  XIX.  p.  486.  Mr.  Moyle  details  a  history,  where  the 
abscess  first  of  all  burst,  inconsequence  of  leaping  over  a  hedge.  Bones  con- 
tinued to  be  discharged  for  a  year,  without  much  injury  to  the  health.  The  ab- 
scess then  healed,  but  three  years  afterwards  a  tumour  again  appeared,  and,  in 
consequence  of  exertion,  burst ;  when  about  a  yard  of  intestine  protruded.  Some 
days  elapsed  before  Mr.  Moyle  saw  her.  The  intestine  was  then  gangrenous, 
but  she  lived  12  days  longer,  and  the  portion  was  thrown  off  before  death.  Med. 
Jour.  Vol.  VI.  p.  52. 


207 

stomach.  She  is  sick  or  vomits  in  the  morning,  and  has  returning 
qualms  or  fits  of  languor  during;  the  forenoon;  is  liable  to  heart- 
burn through  the  day  or  in  the  evening,  and  to  that  disturbed  sleep 
through  the  night,  which  so  frequently  attends  abdominal  irritation. 
In  some  instances,  the  mind  also  is  affected,  becoming  unusually 
irritable,  changeable,  or  melancholy.  The  breasts  often  at  first 
become  smaller,  but  about  the  third  month  they  enlarge,  and  oc- 
casionally become  painful ;  the  nipple  is  surrounded  with  a  brown 
circle  or  areola;  and  often,  even  at  an  early  period,  a  serous  fluid 
begins  to  ooze  from  it.  She  looses  her  looks,  becomes  paler,  and 
the  under  part  of  the  lower  eye-lid  is  of  a  leaden  hue.  The  fea- 
tures become  sharper,  and  sometimes  the  whole  body  begins  to  be 
emaciated,  whilst  the  pulse  quickens.  In  many  instances,  particu- 
lar sympathies  take  place,  causing  salivation,  tooth-ach,  jaundice, 
Sec.  In  other  cases,  very  little  disturbance  is  produced,  and  the 
woman  is  not  certain  of  her  condition,  until  the  period  of  quick- 
ening. 

Some  females,  at  the  time  of  conception,  have  a  slight  discharge 
of  blood  from  the  uterus,  and  in  almost  every  case  the  menses  are 
afterwards  suppressed.  It  has,  however,  been  disputed,  how  far 
this  suppression  is  an  invariable  effect  of  pregnancy.  That  some 
have  been  regular  during  the  whole  time  of  gestation  is  attested  by 
distinguished  practitioners,  whilst  others,  no  less  eminent,  maintain, 
that  although  repeated  sanguinous  discharges,  like  menstruation, 
m»iy  take  place,  yet  these  are  neither  regular,  as  to  the  months- 
period,  nor  exactly  of  the  quantity  of  the  menses.  I  have  not 
known  any  instance  where  menstruation  was  perfect  and  regular 
during  the  whole  of  pregnancy. 

In  the  commencement  of  pregnancy,  the  abdomen  does  not  be- 
come tumid,  but,  on  the  contrary,  is  often  rather  flatter  than  for- 
merly ;  and,  when  it  does  first  increase  in  size,  it  is  rather  from  in- 
flation of  the  bowels,  than  from  expansion  of  the  uterus.  As  an  in- 
crease of  bulk,  together  with  many  of  the  other  symptoms  of  ges- 
tation, may  proceed  from  suppression  of  the  menses,  wc  cannot 
positively,  from  those  signs,  pronounce  a  woman  to  be  with  child. 
The  enlargement  of  tho  belly  is  at  first  accompanied  with  tension 


208 

or  uneasiness  about  the  navel,  which  becomes  rather  prominent, 
especially  toward  the  sixth  month. 

When  women  have  any  doubt  with  regard  to  their  situation,  they 
generally  look  forward  to  the  end  ol'  the  second  quarter  of  preg- 
nancy, as  a  period  which  can  ascertain  their  condition.  For,  about 
the  end  of  the  fourth  month,  or  a  little  sooner  or  later,  in  different 
women,  the  uterus  ascends  out  of  the  pelvis,  and  the  motion  of 
the  child  is  first  perceived,  or  it  is  said  to  quicken  ;(u)  and,  in 
some  cases,  a  few  drops  of  blood  flow  from  the  uterus  at  this  period. 

(~uj  Professor  Rocderer  kept  a  correct  account  of  one  hundred  women,  not- 
ing the  time  when  it  was  presumed  they  were  impregnated,  the  period  at 
which  they  quickened,  and  again,  the  time  when  they  were  delivered.  Out  of 
this  number  we  are  informed,  that  eighty  quickened  at  the  fourth  month,  a  por- 
tion of  the  remainder  quickened  at  the  the  third  month,  and  the  rest  went  on  to 
the  fifth.  Therefore,  we  may  with  great  propriety  consider  four  months  as  the 
general  time  of  quickening ;  and  upon  rinding  that  a  woman  has  quickened, 
within  a  day  or  two,  we  may  with  great  confidence  calculate  that  she  has  five 
months  to  go. 

The  term  quickening,  is  certainly  not  the  most  accurate  phrase  that  could  be 
selected,  to  express  the  simple  fact  of  the  uterus  rising  above  the  brim  or  cavity 
of  the  pelvis. 

It  is  well  known  that  the  impregnated  uterus  generally  remains  in  the  pelvis, 
as  we  have  just  observed,  until  the  latter  part  of  the  fourth  month  ;  and  that  after 
this  period,  as  it  enlarges,  it  necessarily  rises  above  that  cavity  into  the  abdomen  ; 
but  it  is  to  be  remarked — 

1.  The  ascent  of  the  impregnated  uterus  from  its  position  in  the  pelvis  to  its 
subsequent  station,  is  sometimes  gradual  and  unobserved;  of  course,  the  sensa- 
tion of  quickening  is  not  then  felt. 

2.  The  uterus  is  sometimes  so  impacted  in  the  cavity  of  the  pelvis,  as  not  to 
reach  its  final  station  within  the  abdomen  without  the  assistance  of  art,  produc- 
ing the  disease  called  retroverted  uterus,  during  which,  quickening  is  never  felt. 

o.  At  other  times,  and  those  frequent,  though  not  constant,  there  exists  some 
slight  impediment  to  the  ascent  of  the  uterus,  -which  being  suddenly  overcome,  t)U- 
viscus  rises  at  once  into  the  abdominal  cavity,  constituting  -what  has  been  referredto  the 
fmtus,  under  the  term  quickening. 

The  sudden  intrusion,  therefore,  of  the  volume  of  the  uterus  among  the  abdo- 
minal viscera,  accompanied  by  as  sudden  a  removal  of  pressure  from  the  iliac  ves- 
sels, is  supposed  to  be  equal  to  produce  the  sensation  we  have  above  noticed. 

We  may  then  state,  "  That  the  sensation  of  quickening  is  felt  in  transitu,  at  the 
moment  when  the  uterus,  removing  from  the  pelvis,  enters  the  abdominal  cavi- 
ty."   Vide  Eclectic  Repertory,  Vol.  III.  p.  30.  October.  No.  IX. 


309 

Some  quicken  at  the  end  of  the  third,  and  others  not  till  the  fifth 
month,  which  may  depend  on  the  size  of  the  pelvis,  the  growth  of 
the  uterus,  and  quantity  of  fluid  it  contains.  The  motion  is  first 
felt  in  the  hypogastrium,  and  is  languid  and  indistinct,  but  by  de- 
grees it  becomes  stronger.  It  is  possible  for  women  to  mistake  the 
effects  of  wind  for  the  motion  of  a  child,  especially  if  they  have 
never  borne  children,  and  be  anxious  for  a  family.  But  the  sensa- 
tion produced  by  wind  in  the  bowels  is  not  confined  to  one  spot, 
but  veiy  often  is  referred  to  a  part  of  the  abdomen,  where  the  mo- 
tion of  the  child  could  not  possibly  be  felt.  It  is  not  to  be  supposed, 
that  the  child  is  not  alive  till  the  period  of  quickening,  though  the 
code  of  criminal  law  is  absurdly  founded  on  that  idea.  The  child 
is  alive  from  the  first  moment  that  it  becomes  visible,  but  the 
phenomena  of  life  must  vary  much  at  different  periods.  The 
child  is  not  felt  to  move  till  after  the  ascent  of  the  uterus  out  of  the 
pelvis.  Does  this  arise  from  any  change  of  the  phenomena  of  life 
at  that  time  in  the  child  itself,  or  from  the  muscular  power  becom- 
ing stronger,  or  from  the  uterus  now  being  in  a  situation,  where, 
there  being  more  sensibility,  the  motion  is  better  felt?  All  of 
these  probably  contribute  to  the  sensation,  which  becomes  stronger 
as  the  child  acquires  more  vigour,  and  as  the  relative  proportion 
of  liquor  amnii  decreases.  This  foetal  motion,  however,  is  not  to 
be  confounded  with  the  sensation  felt  by  the  mother  from  the  ute- 
rus rising  out  of  the  pelvis,  and  which  precedes  the  feeling  of  flut- 
tering. If  this  elevation  shall  take  place  suddenly,  the  sensation 
accompanying  it  is  pretty  strong,  and  the  woman  at  the  time  often 
feels  sick  or  faint,  and,  in  irritable  habits,  even  an  hysterical  fit 
may  attend  it.  From  the  time  when  this  is  felt,  women  are  said 
to  have  quickened,  and  they  afterwards  expect  to  be  conscious  of 
the  motion  of  the  child.  This  motion  in  many,  soon  increases,  and 
becomes  very  vigorous ;  in  others,  it  is  languid  during  the  whole 
of  pregnancy  ;  and  in  a  few  cases,  scarcely  any  motion  has  been 
felt,  although  the  child  at  birth  is  large  and  lively.  The  morning 
sickness,  and  many  of  the  sympathetic  effects  of  pregnancy,  gene* 
rally  abate  after  this,  and  the  health  improves  during  the  two  last 
quarter?. 

28 


210 

Many  women  suppose,  that,  by  examining  the  blood  drawn  from 
the  veins,  their  pregnancy  may  be  ascertained.  ~  Very  soon  after 
impregnation,  the  blood  becomes  sizy ;  but  it  differs  from  the  blood 
of  a  person  affected  with  inflammation.  In  the  latter  case,  the  sur- 
face of  the  crassamentum  is  dense,  firm,  and  of  a  buff  colour,  and 
more  or  less  depressed  in  the  centre.  But  in  pregnancy  the  sur- 
face is  not  depressed,  the  coagulum  is  of  a  softer  texture,  of  a  yel- 
low, and  more  oily  appearance.  It  is  not  possible,  however,  to  de- 
termine positively,  from  inspecting  the  blood;  for  a  pregnant  wo- 
man may  have  some  local  disease,  giving  the  blood  a  truly  inflam- 
matory appearance ;  and,  on  the  other  hand,  it  is  possible  for  the 
suppression  of  the  menses,  accompanied  with  a  febrile  state,  to 
give  the  blood  the  appearance  which  it  has  in  pregnancy. 

Examination  of  the  uterus  itself  is  a  more  certain  mode  of  as- 
certaining pregnancy.  About  the  second  month  of  gestation,  the 
uterus  may  be  felt  prolapsing  lower  in  the  vagina  than  formerly  ; 
its  mouth  is  not  directed  so  much  forward  as  before  impregnation ; 
it  is  shut  up,  and  the  cervix  is  felt  to  be  thicker,  or  increased  in 
circumference.  When  raised  on  the  finger,  it  is  found  to  be  hea- 
vier, or  more  resisting.  Some  have  advised,  that  the  os  uteri  should 
be  raised  upward  and  forward,  so  as  to  retrovert  the  womb,  in  or- 
der that  its  body  may  be  felt,  but  this  is  not  expedient.  Examina- 
tion, at  this  period,  is  liable  to  uncertainty,  because  the  uterus  of 
one  woman  is  naturally  different  in  magnitude  from  that  of  another. 
But,  in  the  third  month,  we  can  arrive  at  tolerable  certainty,  the 
womb  being  then  felt  decidedly  to  be  heavier,  and  more  easily  ba- 
lanced on  the  finger ;  during  which  something  can  be  felt  to  be 
floating  within  the  uterus.  In  the  beginning  of  the  fifth  month,  it  is 
found  to  be  higher  than  when  unimpregnated  :  a  kind  of  fluctua- 
tion may  be  perceived,  and  by  placing  the  hand  on  the  lower  part 
of  the  belly,  so  as  to  press  on  the  fundus  of  the  womb,  it  can  be 
made  to  give  more  resistance  to  the  finger  applied  per  vaginam, 
and  may  by  it  be  rolled  about.  After  quickening,  if  we  pat  with 
the  finger  on  the  cervix  uteri,  we  can  generally  make  the  child 
strike  gently,  so  as  to  be  felt.  About  this  time,  and  still  more  dis- 
tinctly afterwards,  we  can,  if  the  abdominal  muscles  be  relaxed. 


211 

feel  the  uterus  extending  up  from  the  symphysis  pubis,  and,  in 
proportion  as  pregnancy  advances,  can  more  readily  distinguish 
the  members  of  the  child,  and  feel  its  jerks  or  motions.  Exami- 
nation, per  vaginam,  informs  us  of  those  changes  of  the  cervix  and 
os  uteri,  which  were  noticed  in  a  former  chapter. 

A  simple  suppression  of  the  menses  is  apt  to  be  mistaken  for 
pregnancy;  nor  is  it  easy  to  distinguish,  for  some  time,  between 
them ;  but  the  doubt  is  soon  cleared  up  by  the  state  of  the  womb, 
and  the  want  of  motion  at  the  proper  period.  In  pregnancy,  the 
uterus  early  descends  somewhat  in  the  pelvis,  and  its  mouth  be- 
comes more  circular,  in  place  of  being  transverse,  whilst  the  gene- 
ral bulk  of  the  womb  and  its  weight  are  increased.  Simple  infla- 
tion of  the  bowels,  with  suppression  of  the  menses,  cannot  mislead, 
if  the  state  of  the  uterus  be  attended  to ;  and,  at  an  advanced  pe- 
riod, the  lower  belly  is  found  soft  or  puffy. 

Not  unfrequently,  a  diseased  ovarium  makes  the  patient  suppose 
herself  pregnant,  even  although  she  should  have  the  counter  evi- 
dence of  menstruation.  For  the  abdomen  is  large,  and  the  ovari- 
um is  felt  through  the  parietes,  sometimes  pretty  high,  like  the 
uterus,  or  like  a  prominent  part  of  a  child.  The  tumour  is  acted 
on  so  far  by  the  aorta  as  to  occasion,  at  times,  a  sense  of  pulsation, 
which  is  mistaken  for  the  motion  of  the  child.  Per  vaginam  the 
uterus  is  felt  high,  and  its  cervix  often  apparently  developed  from 
being  raised,  and  the  vagina  elongated,  whilst  the  os  uteri  itself  may 
have  its  lips  shortened.  No  child,  however,  can  be  felt,  nor  any- 
distinct  expansion  of  the  lower  part  of  the  uterus,  whilst  externally 
the  round  and  circumscribed  tumour  of  the  ovarium  may  be  dis- 
tinguished. 


212 

CHAP.  XX. 

Of  the  Diseases  of  Pregnant  Women. 
§  1.  GENERAL  EFFECTS. 

Pregnancy  produces  an  effect  on  the  general  system,  marked 
often  by  a  degree  of  fever,  and  always  by  an  altered  state  of  the 
blood.  This  state  is  the  consequence  of  local  increased  action, 
which  irritates  and  excites  the  system,  in  the  same  way  as  when 
an  organ  is  inflamed.  There  would  appear  to  be,  likewise,  a  ten- 
dency to  the  formation  of  more  blood  than  formerly,  and  the  ner- 
vous system  is  evidently  rendered  more  irritable.  The  gravid 
uterus,  also,  has  an  effect  by  sympathy,  on  other  organs  or  viscera ; 
and  likewise  produces  changes  in  them,  mechanically,  by  its  bulk 
and  pressure. 

The  effect  of  irritation,  or  changes  in  the  condition  of  the  ex- 
tremities of  the  abdominal  nerves,  on  the  sensorium  commune, 
and  whole  nervous  system,  as  well  as  on  the  arterial  action,  is  so 
fully  proved,  that  it  is  not  necessary  to  enter  minutely  here  into 
that  subject.  It  is,  however,  of  great  importance,  that  it  should  be 
borne  in  mind,  in  our  pathological  reasoning ;  although  we  are  not 
yet  prepared  to  explain,  or,  what  is  worse,  to  detail,  many  facts  of 
practical  value.  The  origin  and  distribution  of  the  par  vagum, 
and  great  intercostal  nerves,  might  lead  to  the  expectation  of  very 
important  and  intricate  sympathies.  Temporary  affection  of  cer- 
tain portions  of  the  intestinal  canal  produces  pain  in  one  eye  or 
side  of  the  head ;  when  another  portion  is  affected,  or  perhaps  the 
same  portion,  in  a  different  degree,  the  opposite  side  suffers,  or 
the  whole  forehead  is  pained,  or  the  upper  part  of  the  spinal  mar- 
row sympathizes,  and  a  secondary  but  most  marked  train  of  symp- 
toms is  thereby  produced ;  cough,  feeling  of  suffocation,  numbness, 
or  spasms.  Another  affection  of  the  bowels  gives  rise  to  convul- 
sive agitation  of  the  muscles;  whilst,  once  more,  we  find  irritation, 
particularly  of  the  small  intestines,  sometimes  occasions  drowsi- 


215 

ness,  or  a  feeling  of  fulness  and  giddiness  in  the  head,  sometime? 
occasioning  even  a  temporary  insensibility,  or  paralysis.  Hence 
some  varieties  of  apoplexy  and  palsy  are  originally  dependent  on 
affections  of  the  bowels;  and  hence  the  distressing,  and,  in  many 
cases,  injurious,  effects  produced  by  inefficient  doses  of  laxatives, 
which  irritate  partially,  without  exciting  briskly  and  universally, 
or  in  speedy  succession,  the  whole  tract  of  the  intestines.  Hence 
the  impropriety  of  employing  certain  mineral  waters,  in  cephalic 
affections,  more  especially  if  not  aided  by  exercise,  or  an  addi- 
tional laxative  to  excite  briskly.  Hence  the  origin  of  sick  head- 
ach,  of  many  hysterical  and  anomalous  affections,  of  chorea,  and 
disorders  of  the  sanguiferous  system;  and  hence  the  most  valuable, 
but  too  often  disregarded,  fact,  that  many  excitements,  arising 
clearly  from  the  bowels,  or  state  of  the  abdominal  nerves,  are, 
from  this  indirect  influence  on  the  vascular  system,  best  relieved 
by  resorting  to  the  lancet,  before  acting  on  the  original  seat  of  the 
disease  by  purgatives,  which  would  be  too  slow  in  their  operation. 
The  uterus  may  directly  influence  the  system,  producing  much  ir- 
ritation and  many  disordered  actions,  and  so  doubtless  may  the 
stomach  and  liver;  but  I  question  whether  these  different  organs 
do  not  more  frequently  cause  sympathetic  disorders  through  the 
medium  of  the  intestines.  Even  in  many  cases  of  dyspepsia,  per- 
haps in  most  not  dependent  on  organic  disease,  the  complaint  is 
referrible  to  the  intestines,  secretion  of  bile,  crudity  in  the  stomach, 
sickness  and  headach ;  depending  more  on  the  state  of  the  bowels 
than  on  primary  disorders  of  the  stomach.  Hence  dyspeptic 
patients  are  sure  to  suffer,  if  they  take  much  liquid,  or  soups,  or 
acidifiable  diet,  or  aliment  which  passes  easily  out  of  the  stomach, 
and  is  possessed  of  a  gently  laxative  quality ;  for  thereby  the  in- 
testines are  excited  to  a  hurtful,  but  not  to  a  sufficient  degree ; 
they  are  irritated,  but  not  to  efficient  action.  A  diet  too  light  is, 
therefore,  equally  bad,  in  such  cases,  with  one  which  is  heavy  and 
indigestible  ;  and  that  diet  is  best  which  neither  passes  too  readily 
through  the  changes  to  be  produced  on  it  in  the  stomach,  nor  re- 
sists too  long,  nor  runs  rapidly  into  acetous  fermentation.  Every 
invalid  must,  to  a  certain  degree,  regulate  his  diet  by  experience ; 
but  when  an  acute  attack  is  brought  on,  ho  will  find  it  still  a  desi- 


214 

deratum  to  obtain  a  medicine  which  will  rapidly  and  briskly  excite 
the  intestinal  action,  without  occasioning  a  long  interval  of  sick- 
ness, or  being  succeeded  by  debility  of  the  canal. 

Effects  both  powerful  and  varied  are  often  produced  by  the 
uterus  in  a  state  of  gravidity.  These  may  be  divided  into  those 
arising  from  sympathy  between  the  uterus  and  other  abdominal 
viscera,  and  confined  to  these;  into  those  exhibited  in  more  re- 
mote parts,  whether  occasioned  by  sympathy  directly  with  the 
uterus,  or  indirectly  through  the  medium  of  the  sympathising  in- 
testines ;  and  into  those  arising  more  purely  from  mechanical  pres- 
sure. 

The  effects  of  pregnancy  vary  much,  both  in  degree,  and  in  the 
nature  and  combination  of  the  symptoms,  according  to  the  consti- 
tution of  the  woman,  and  the  natural  or  acquired  irritability  of 
different  organs.  In  a  few  cases,  a  very  salutary  change  is  pro- 
duced on  the  whole  system,  so  that  the  person  enjoys  better 
health,  during  pregnancy,  than  at  other  times.  But  in  most  in- 
stances, troublesome  or  inconvenient  symptoms  are  excited, 
which  are  called  the  diseases  of  pregnancy,  and  which,  in  some 
women,  proceed  so  far,  as  not  only  to  deprive  them  of  all  enjoy- 
ment and  comfort,  but  even  to  produce  considerable  fear  of  their 
safety. 

As  these  proceed  from  the  state  of  the  uterus,  it  follows,  that 
when  they  exist,  in  a  moderate  degree,  they  neither  admit  of,  nor 
require  any  attempts  to  cure  them;  for  their  removal  implies  a 
stoppage  of  the  action  of  gestation,  which  is  their  cause.  But  when 
any  of  the  effects  are  carried  to  a  troublesome  extent,  then  we  are 
applied  to,  and  may  palliate,  though  we  cannot  take  them  away. 
This  we  do  by  lessening  plethora,  if  necessary,  by  blood-letting, 
and  allaying  the  increased  irritability  of  the  system  by  the  regular 
use  of  laxatives,  which  remove  that  particular  state  of  the  bowels, 
which  is  so  apt  to  cause  restlessness  and  nervous  irritation.  If 
these  are  not  altogether  successful,  the  camphorated  julap  is  a  use- 
ful medicine.*    Besides  this  general  plan,  we  must  diminish  the 

*  Petit,  and  many  after  him,  have  been  of  opinion,  that  opium  is  hurtful  dur- 
ing gestation ;  and  there  can  be  no  doubt  that  it  generally  is  so,  when  given  fre- 


215 

febrile  state  of  the  system,  where  such  exists,  by  regulation  of  the 
diet,  and  suitable  remedies.  Individual  symptoms  must  be  treated 
on  general  principles. 

There  is  a  great  diversity,  both  in  the  effects  of  pregnancy,  and 
also  in  the  period  at  which  these  manifest  themselves;  for  whilst 
some  begin  to  suffer  very  early  from  the  irritation  of  the  uterus, 
and  are  much  relieved  from  the  effects  thereof,  after  the  child 
quickens,  others  feel  very  little  inconvenience  till  towards  the  end 
of  pregnancy,  or  the  last  quarter,  when  the  womb  is  greatly  en- 
larged, and  the  abdominal  viscera  disturbed. 

In  the  dietetic  part  of  our  treatment,  we  must  bear  in  mind  that 
we  ought  neither  to  admit  of  such  regimen  as  shall  fill  the  vessels 
with  too  much  fluid,  nor  throw  the  organs  of  digestion  into  disor- 
der. Much  liquid,  even  of  the  mildest  nature,  ought  to  be  avoided, 
and  the  aliment  must  neither  be  too  rich  nor  too  acescent.  Re- 
gard, however,  must  be  had,  in  our  directions,  to  the  state  of  the 
patient,  and  the  risks  to  be  apprehended,  on  the  one  hand,  from 
plethora,  and,  on  the  other,  from  debility.  Wherever  fruit  agrees 
with  the  patient,  it  may  be  freely  allowed,  and  the  same  may  be 
said  of  well-boiled  vegetables;  but  when  these  occasion  acid  or 
flatulence,  they  must  be  refrained  from.  It  is  of  much  importance 
to  preserve  the  bowels  in  a  correct  and  active  state.  The  exercise 
to  be  taken,  or  permitted,  must  be  regulated  by  the  probable  chance 
of  abortion  resulting. 

§  2.  FEBRILE  STATE. 

In  many  cases,  the  pulse  becomes  somewhat  quicker,  soon  after 
impregnation,  and  the  heat  of  the  skin  is  at  the  same  time  a  little 
increased,  especially  in  the  evenings.  In  the  latter  months  of  preg- 
nancy, the  febrile  symptoms  in  some  instances  are  extremely  trou- 
blesome ;  the  pulse  is  permanently  frequent,  but  in  the  evenings  it 
is  more  accelerated,  whilst  the  skin  becomes  hot,  and  the  woman 

quently.  It  is  detrimental,  both  by  its  effects  upon  the  stomach  and  bowels,  and 
on  the  system  at  large.  In  severe  spasms,  or  great  irritation,  it  may  be  necessary, 
but  it  never  ought  to  be  often  repeated,  as  it  ultimately  increases  the  irritabili- 
ty, and  injures  the  bowels,  as  it  would  do  in  chorea. 


216 

restless ;  she  cannot  sleep,  but  tosses  about  till  day-break,  when 
she  procures  short  unrefreshing  slumber,  occasionally  accompanied 
with  a  partial  perspiration.  In  the  morning,  the  febrile  symptoms 
are  found  to  have  subsided ;  but  in  the  afternoon  they  return,  and 
the  following  night  is  spent  alike  uncomfortably. 

This  state  is  attended  with  more  emaciation,  and  greater  sharp- 
ness of  features,  than  is  met  with  in  pregnancy  under  different  cir- 
cumstances ;  but  it  is  wonderful  how  well  the  strength  is  kept  up, 
in  spite  of  the  want  of  rest,  and  of  the  uneasiness  which  is  pro- 
duced, from  this  disease  being  sometimes  conjoined  with  intolera- 
ble heat  about  the  parts  of  generation. 

In  slight  degrees  of  this  febrile  state,  all  that  is  necessary  is  se- 
dulously to  keep  the  bowels  open,  and  take  away  a  little  blood. 
But  when  it  becomes  urgent,  towards  the  last  months  of  gestation, 
we  are  under  the  necessity  of  taking  away  blood  more  frequently, 
but  not  in  great  quantity  at  a  time ;  and  always  in  doing  so,  having 
regard  to  the  constitution  of  the  patient.  The  saline  julap  is  of  con- 
siderable service,  by  producing  a  gentle  moisture,  but  a  copious 
perspiration  is  neither  necessary  nor  useful.  The  julap  may  either 
be  given  in  repeated  doses,  through  the  day,  or  merely  one  or  two 
doses  in  the  morning,  or  early  part  of  the  night,  according  to  cir- 
cumstances. The  bowels  are  to  be  kept  open  by  a  mild  laxative, 
such  as  the  aloetic  pill,  or  rhubarb  and  magnesia.  The  sulphuric 
acid  is  a  very  good  internal  medicine.  The  restlessness  is  best  al- 
layed by  sleeping  with  few  bed-clothes  ;  and  sometimes  great  re- 
lief is  obtained,  by  dipping  the  hands  in  water,  or  grasping  a  wet 
sponge.  Opiates  very  seldom  give  relief,  and  ought  not  to  be 
pushed  far,  as  they  make  the  patient  more  uncomfortable,  and  are 
supposed  even  to  injure  the  child ;  at  all  events,  if  the  occasional 
exhibition,  on  any  emergency,  of  a  moderate  dose  of  opium  or  hy- 
oscyamus,  fail  to  procure  comfortable  sleep,  no  benefit  is  to  ex- 
pected from  increasing  the  quantity.  Frequently  nothing  does 
much  good,  the  state  continuing  until  the  woman  is  delivered.  I 
need  scarcely  add,  that  we  must  take  care  not  to  confound  this, 
which  may  be  called  the  fever  of  pregnancy,  with  that  arising  from 
local  disease,  as  for  instance  in  the  lungs  or  liver. 


217 

There  is  a  species  of  fever,  which  may  affect  women  about  the 
middle  of  pregnancy,  and  makes  its  attack  suddenly,  like  a  regular 
paroxysm  of  ague.  It  soon  puts  on  an  appearance  rather  of  hectic, 
combined  with  hysterical  symptoms.  The  head  is  generally  at  first 
pained,  or  the  patient  complains  of  much  noise  within  it,  sleeps 
little,  has  a  loathing  at  food,  with  a  foul  dry  tongue,  and  a  consider- 
able thirst,  whilst  the  bowels  are  constipated.  Sometimes  she  talks 
incoherently,  or  moans  much  during  her  slumber,  and  has  fright- 
ful dreams :  occasionally  a  cough,  or  distressing  vomiting  super- 
venes. This^  disease  is  very  obstinate,  and  often  ends  in  abortion  ; 
after  which,  if  the  patient  do  not  sink  speedily  under  the  effects 
of  the  process,  she  begins  to  recover,  but  remains  long  in  a  chlo- 
rotic  state,  which,  if  not  removed,  may  terminate  in  phthisis.  I 
strongly  suspect  that  this  disease  originates  from  the  bowels,  and 
bears  great  analogy  to  the  infantile  remitting  fever.  It  is  usually 
preceded  by  costiveness,  and  is  sometimes  apparently  excited  by 
irregularities  in  diet.  We  ought,  on  the  first  attack  of  the  cool  fit, 
to  check  it  by  warm  diluents,  with  the  saline  julap.  If  the  proper 
opportunity  be  lost,  or  these  means  fail,  we  must  lessen  irritation, 
by  detracting  some  blood ;  open  the  bowels  freely,  and  afterwards 
prevent  feculent  accumulation,  keep  the  surface  moist,  and  palliate 
troublesome  symptoms.  If  the  tongue  be  early  loaded,  and  the 
patient  is  sick  or  squeamish,  a  very  gentle  emetic  will  be  proper. 
The  strength  is  to  be  supported.  In  a  state  of  convalescence, 
gentle  exercise  and  pure  air  are  useful,  but  every  exertion  must  be 
avoided. 

§  3.  VOMITING. 

Vomiting  is  a  very  frequent  effect  of  pregnancy,  and  occasionally 
begins  almost  immediately  after  conception.  Generally  it  take- 
place  only  in  the  morning,  immediately  after  getting  up,  and  hence 
it  has  been  called  the  morning  sickness;  but,  in  a  few  instances,  it 
does  not  come  on  till  the  afternoon.  It  usually  continues  until  the 
period  of  quickening,  after  which  it  decrpase«  or  ^oes  off.  bin. 

20 


218 

sometimes  it  remains  during  the  whole  of  gestation.  Some  women 
do  not  vomit,  and  have  very  little  if  any  sickness;  others  begin, 
after  the  fourth  month,  to  feel  an  irritation  about  the  stomach  and 
other  viscera;  and  some  remain  free  from  inconvenience  till  the 
conclusion  of  pregnancy,  when  the  distention  of  the  womb  affects 
the  stomach.  The  fluid  thrown  up  is  generally  glairy  or  phlegm, 
and  the  mouth  fills  with  water  previous  to  vomiting ;  but  if  the 
vomiting  be  severe  or  repeated,  bilious  fluid  is  ejected.  Generally 
there  is  no  occasion  to  prescribe  any  remedies.  Puzos,  and 
others,  even  considered  vomiting  as  salutary ;  but  in  some  cases, 
it  goes  to  a  very  great  length,  recurring  whenever  the  woman  eats, 
or  sometimes  even  when  she  abstains  from  eating,  and  continues 
for  days  or  even  weeks  so  obstinate,  that  she  is  in  danger  of  mis- 
carrying,* or  of  suffering  from  want  of  food.  It  is  a  general  rule, 
in  such  cases,  to  take  away  early  a  small  quantity  of  blood,  a 
quantity  proportioned  to  the  vigour  and  fulness  of  the  habit  and 
state  of  the  pulse.  Of  the  utility  of  this  practice,  the  general  tes- 
timony of  practitioners,  and  my  own  observation,  fully  convince 
me.  Narcotic  substances,  such  as  opium  or  hyoscyamus  have 
been  tried  internally,  either  without  blood-letting  or  subsequent  to 
it,  but  uniformly  with  little  advantage.  In  a  few  instances,  a  cloth 
wet  with  laudanum  applied  to  the  pit  of  the  stomach,  has  done 
good.  The  greatest  attention  must  be  paid  to  the  bowels,  and 
most  marked  benefit  is  often  derived  from  a  gentle  dose  of  Epsom 
or  Cheltenham  salts.  The  severity  of  the  vomiting  may  also  be 
greatly  mitigated  by  effervescing  draughts,  or  soda  water :  the 
last  of  which,  if  it  do  not  check  the  vomiting,  renders  it  much 
easier.  Even  cold  water  has  been  employed  with  advantage.  A 
light  bitter  infusion  is  sometimes  of  service.  Obstinate  vomiting, 
especially  if  accompanied  with  pain,  or  tension  in  the  epigastric 
region,  may  be  relieved  by  the  application  of  leeches  to  that  part, 
which  have  been  much  recommended  by  Dr.  John  Sims  and  M. 
Lorentz.  I  have  so  often  found  advantage  from  this  remedy,  that 
I  speak  of  it  with  confidence.     If  these  means  fail  in  procuring 

*  It  is  worthy  of  remark,  that  abortion  is  very  seldom  occasioned  by  this  cause . 
though  emetics  are  apt  to  produce  it. 


219 

speedy  relief,  it  is  necessary  to  refrain  for  a  time  eating,  and  have 
recourse  to  nourishing  clysters,  or  to  give  only  a  spoonful  of  milk, 
soup,  &c.  at  a  time.  When  the  vomiting  is  bilious,  and  accom- 
panied with  pain  in  the  right  side  and  shoulder,  cough,  and  other 
symptoms  of  hepatitis,  a  seton  should  be  immediately  introduced 
into  the  side,  and  a  very  gentle  course  of  mercury  given,  with  cir- 
cumspection ;  for  if  the  medicine  be  given  freely,  it  produces  much 
debility,  or  abortion,  and  sometimes  accelerates  the  fate  of  the 
patient. 

When  vomiting  is  troublesome  in  the  conclusion  of  pregnancy, 
it  is  proper  to  detract  blood,  and  confine  the  person  to  bed. 
Cloths,  dipped  in  laudanum,  should  be  applied  to  the  pit  of  the 
stomach,  and  a  grain  of  solid  opium  may  be  given  internally ;  but 
if  this  do  not  succeed,  it  is  not  proper  to  give  larger  and  repeated 
doses.     Gentle  laxatives  must  be  employed. 

§  4.  HEARTBURN. 

Heartburn  often  takes  place  very  early  after  conception,  but 
sometimes  not  till  after  the  fourth  month.  This  is  a  complaint  so 
very  common,  and  so  generally  mitigated  by  absorbents,  such  as 
magnesia,  soda,  or  chalk,  that  we  are  seldom  consulted  respecting 
it.  But  when  it  becomes  very  severe  and  intractable,  it  is  requi- 
site to  try  the  most  powerful  of  these  means,  such  as  calcined 
magnesia,  combined  with  pure  ammonia.^     When  these  fail, 

(~xj  The  late  much  regretted  Dr.  Young,  of  Maryland,  in  his  ingenious  ex- 
periments on  the  digestive  process,  has  almost  reduced  it  to  a  certainty,  that  the 
acid  which  exists  in  the  stomach  is  to  be  referred  to  the  liquor  gastricus ;  that  it 
is  the  phosphoric  acid,  and  that  the  acidity  of  dyspeptic  and  pregnant  women, 
is  owing  to  the  morbid  quantity  of  this  acid.  Hence,  as  he  justly  remarks,  the 
superiority  of  lime  water  as  a  corrector,  from  its  great  affinity  to  phosphoric 
acid. 

The  following  formula  is  also  recommended  by  experienced  practitioners  for 
the  same  purpose.    I  have  used  it  with  advantage. 

R.  Magnesiae  ustae  gj. 

Aquae  purae  ovss- 

Sp.  Cinnamon  jiij. 

Aquae  Ammoniae  purae  gj  m. 

Two  or  three  spoonfuls  to  he  taken  either  occasionally,  or  when  the  symp» 
toms  are  more  continual,  immediately  after  every  meal. 


220 

liquor  potassae,  or  the  chalk  mixture,  with  a  large  proportion  of 
mucilage,  may  give  relief.  Laxatives  are  always  indispensable. 
In  obstinate  cases,  venesection  is  useful.  Emetics  have  been  pro- 
posed by  Dr.  Denman.  They  are  only  allowable  where  there  is 
a  constant  screatus  of  disagreeable  phlegm.  In  every  severe  case 
the  diet  must  be  carefully  attended  to. 

Pyrosis  is  to  be  relieved  chiefly  by  laxatives,  such  as  the  aloetic 
pill,  with  extract  of  colocynth,  some  light  bitter,  or  rhubarb  and 
magnesia.  If  these  means  fail,  antispasmodics  may  be  useful,  and 
rubbing  the  epigastric  region  with  anodyne  balsam. 


§  5.  FASTIDIOUS  TASTE. 

Women,  during  gestation,  are  subject  to  many  bizarreries  in  their 
appetite,  and  often  have  a  desire  to  eat  things  they  did  not  former- 
ly like.  This  desire  is  common  in  cases  of  abdominal  irritation,  as 
we  see  in  those  who  are  afflicted  with  worms,  or  have  indurated 
or  morbid  faeces  in  the  intestines.  These  longings  it  has  been 
thought  dangerous  to  deny;  for  as  it  was  supposed,  that  they  de- 
pend upon  some  peculiar  state  of  the  child  affecting  the  mother,  it 
was  imagined,  that  if  this  was  not  removed,  the  infant  would  sus- 
tain an  injury,  or  might  even  bear  the  mark  of  the  thing  longed  for. 
Into  this  doctrine  it  is  now  unnecessary  to  enter ;  and  it  will  be 
sufficient  to  add,  that  when  the  desire  is  placed  upon  any  article  of 
diet,  it  may  be  safely  gratified,  and,  indeed,  generally  the  inclina- 
tion leads  to  some  light  and  cooling  regimen. 


§  6.  SPASM  OF  STOMACH  AND  DUODENUM. 

Spasm  of  the  stomach,  or  duodenum,  may  often  be  attributed  to 
some  irregularity  of  diet,  to  the  action  of  cold,  or  to  the  influence 
of  the  mind.  It  is  necessary  to  interfere  promptly,  not  only  be- 
cause the  pain  is  severe,  but  also  because  it  may  excite  abortion,  or 
kill  the  child.  A  full  dose  of  laudanum,  with  ether,  followed  im- 
mediately by  a  saline  clyster,  is  almost  always  successful ;  but 
when  the  attacks  are  renewed,  then  we  must  endeavour  to  prevent 


221 

them  by  tonics,  such  as  colomba,  oxyde  of  bismuth,  or  prepara- 
tions of  steel.  It  is  at  the  same  time,  essential  that  the  bowels  be 
kept  open,  and  for  this  purpose,  asafoetida  combined  with  aloes  and 
colocynth  is  well  adapted.  Blood-letting  is  of  service,  if  the  at- 
tack be  prolonged. 

When  spasm  of  the  stomach  takes  place  in  the  end  of  pregnancy, 
or  about  the  commencement  of  parturition,  with  a  sense  of  fulness 
or  uneasiness  in  the  head,  it  is  necessary  to  detract  blood,  lest  the 
patient  be  seized  with  convulsions.  This  remedy  is  likewise  pro- 
per, when  the  pain  is  accompanied  with  tenderness  about  the  epi- 
gastric region,  heat  of  the  skin,  full  pulse,  and  ruddy  face.  When 
pain  proceeds  from  the  passage  of  a  biliary  calculus,  it  is  to  be 
treated  more  solito. 


§  7.  COSTIVENESS. 

Costiveness  is  a  general  attendant  on  pregnancy,  partly  owing  to 
the  pressure  of  the  uterus  on  the  rectum,  and  partly  owing  to  the 
increased  activity  of  the  womb  producing  a  sluggish  motion  of  the 
bowels.  We  must  not,  however,  neglect  this  state,  because  it  na- 
turally attends  gestation,  for  it  may  occasion  many  and  serious 
evils.  It  certainly  increases  the  irritability  of  the  system,  as  well 
as  some  of  the  stomachic  ailments ;  and  is  apt  to  cause  irritation 
of  the  bowels,  which  may  either  excite  premature  labour,  or  give 
rise  to  much  inconvenience  after  delivery,  and  not  unfrequently 
occasions  convulsions. 

Magnesia  is  a  very  common  remedy,  because  it  at  the  same 
time,  relieves  heartburn ;  but,  when  it  fails,  or  is  not  required  for 
curing  acidity  in  the  stomach,  the  common  aloetic  pill,  the  com- 
pound rhubarb  pill,  compound  extract  of  colocynth,  or  a  combina- 
tion of  aloes  with  extract  of  hyoscyamus,  should  the  former  gripe, 
may  be  employed.  Castor  oil  is  also  given,  either  alone,  or  made 
into  an  emulsion  with  mucilage. 

It  sometimes  happens,  that  indurated  faeces  are  accumulated  in 
the  rectum  or  colon,  producing  considerable  irritation.  This  cau- 
ses not  only  pain,  but  also  an  increased  secretion  of  the  intestinal 


222 

mucus  which  is  passed  either  alone,  or  with  blood,  together  with 
pieces  of  hard  faeces.  This  state,  like  dysentery,  is  often  accom- 
panied with  great  tenesmus;  but  it  may  be  readily  distinguished, 
by  examining  per  vaginam,  for  the  rectum  is  found  to  be  filled  with 
fasces.  Our  first  object  ought  to  be  to  remove  the  irritating  cause, 
which  might  ultimately  produce  abortion.  Clysters  are  of  great 
efficacy,  because  they  soften  the  fasces,  and  assist  in  emptyi«g  that 
part  of  the  intestine  which  is  most  distended.  These  are  to  be,  at 
first,  of  a  very  mild  nature,  and  must  be  frequently  repeated.  It 
may  even  be  requisite  to  break  down  the  feculent  mass,  with  the 
shank  of  a  spoon,  or  scoop.(y)  After  the  rectum  is  emptied,  laxa- 
tives, such  as  castor  oil,  or  small  doses  of  sulphate  of  magnesia 
must  be  given  to  evacuate  the  colon;  and  when  the  fasces  are 
brought  into  the  rectum,  clysters  must  be  again  employed.  After 
the  bowels  are  emptied,  hyoscyamus  should  be  given,  to  allay  the 
irritation ;  or  if  this  be  not  sufficient,  and  the  pain  and  secretion  of 
mucus,  with  tenesmus,  still  continue,  an  opiate  clyster  must  be  ad- 
ministered, but  next  day  it  is  to  be  followed  by  a  mild  laxative. 
And  if  there  be  fever,  or  considerable  pain  in  the  abdomen,  blood- 
letting will  be  necessary.  If  this  costive  state  be  neglected  near 
the  time  of  delivery,  the  labour  is  often  protracted ;  and  after  de- 
livery masses  of  indurated  fasces  come  down  from  the  colon,  pro- 
ducing considerable  pain  and  frequency  of  pulse.  When  there  is 
much  irritation  and  sensibility,  upon  pressing  on  the  abdomen, 
either  before  or  after  delivery,  it  will  be  proper  to  detract  blood, 
at  the  same  time  that  we  use  the  remedies  already  pointed  out.  - 


§  8.  DIARRHCEA. 

The  bowels,  instead  of  being  bound,  may  be  very  open  ;  or  cos- 
tiveness  and  diarrhoea  may  alternate  with  each  other.     The  diar- 

(~yj  The  reader  is  referred,  for  a  very  interesting  case  of  alvine  concretion, 
where  it  became  necessary  to  introduce  a  long  flexible  catheter  through  the 
hardened  and  impacted  feces,  occupying  the  superior  part  of  the  pelvis,  for  the 
purpose  of  injecting  an  enema,  to  Hey's  Practical  Observations  on  Surgery, 
chap.  XVIII.  case  3. 


223 

vhcea  is  of  two  kinds ;  a  simple  increase  of  the  peristaltic  motion, 
and  increased  serous  secretion  ;  or  a  more  obstinate  disease,  de- 
pending on  debilitated  and  deranged  action  of  the  bowels.  In  the 
first  kind,  the  discharge  is  not  altered  from  the  natural  state,  ex- 
cept in  being  thinner ;  the  appetite  is  pretty  good,  and  the  tongue 
clean,  or  only  slightly  white.  This  is  not  to  be  checked,  unless  it 
go  to  a  considerable  extent,  or  continue  long,  or  the  patient  be 
weakened  by  it,  or  be  previously  of  a  debilitated  habit.  Anodyne 
clysters,  or  the  confectio  catechu,  will  then  be  of  service.  Should 
the  pulse  be  frequent,  and  any  degree  of  heat  or  tension  be  felt  in 
the  abdomen,  venesection  will  be  useful.  In  the  second  kind,  the 
appetite  is  lost  or  diminished,  the  tongue  is  foul,  and  the  patient 
has  a  bitter  or  bad  taste,  and  occasionally  vomits  ill  tasted  or  bilious 
matter ;  the  breath  is  offensive,  and  often  the  head  aches.  The 
stools  are  very  offensive,  and  generally  dark  coloured.  In  this  case, 
small  doses  of  rhubarb  give  great  relief,  and  one  grain  of  ipecacu- 
anha may  occasionally  be  added  to  each  dose  of  rhubarb.  A 
light  bitter  infusion  is  also  a  useful  remedy.  Attention  must  be  paid 
to  the  diet,  which  is  to  be  light,  and  the  food  taken  in  a  small  quan- 
tity at  a  lime.  Considerable  benefit  is  derived  from  soda  water, 
which  generally  abates  the  sickness.  When  the  tongue  becomes 
cleaner,  and  the  stools  more  natural,  anodyne  clysters  may  be  ad- 
ministered. In  all  cases  of  continued  diarrhoea,  it  is  useful  to  have 
the  surface  kept  warm  with  flannel ;  and  sometimes  a  flannel  roller, 
bound  gently  round  the  abdomen,  gives  great  relief. 

§  9.  PILES. 

Pregnant  women  are  very  subject  to  piles.  This  may  be  partly 
owing  to  the  pressure  of  the  womb  upon  the  vessels  of  the  pelvis, 
but  is  chiefly  to  be  attributed  to  a  sluggish  state  of  the  intestinal 
canal,  communicating  a  similar  torpor  to  the  hemorrhoidal  veins. 
As  this  state  is  attended  with  costiveness,  the  disease  has  been  con- 
sidered as  dependent  on  the  mechanical  action  of  the  feces;  but 
whatever  truth  may  be  in  this  opinion,  in  some  cases,  yet  generally 
it  is  without  foundation  ;  and  it  is  no  unusual  thing  for  those  who 
are  subject  to  piles,  to  be  able  to  foretell  an  attack,  by  the  appear- 


224 

ance  of  peculiar  symptoms,  indicating  diminished  action  of  the  ali- 
mentary canal.  The  treatment  of  this  disease  is  two-fold.  We  are 
to  remove  the  cause  by  such  means  as  give  a  brisker  action  to  the 
bowels,  such  as  bitters  and  laxatives ;  which  last  are  also  of  great 
service  by  removing  the  irritation  of  the  fasces  from  the  rectum,  and 
rendering  them  softer,  by  which  the  expulsion  gives  less  pain.  For 
this  purpose,  cream  of  tartar  alone,  or  combined  with  sulphur,  has 
been  generally  employed;  but  we  may,  with  equal  advantage,  give 
small  doses  of  castor  oil,  or  of  any  of  the  mild  neutral  salts,  dis- 
solved in  a  large  quantity  of  water.  Besides  removing  the  cause, 
we  must  likewise  lessen  the  effect  by  such  local  means  as  abate  ir- 
ritation and  sensibility.  When  the  pain,  inflammation,  and  swelling, 
are  great,  it  is  of  service  to  detract  blood  topically,  by  the  applica- 
tion of  leeches,  or,  especially  if  there  be  considerable  fever,  blood- 
letting may  be  necessary,  as  in  other  cases  of  local  inflammation. 
The  diet  should  be  spare ;  all  stimulants  and  cordials  must  be 
avoided  ;  cooling  and  anodyne  applications  to  the  tumour  are  also 
very  proper,  such  as  an  ointment  containing  a  small  quantity  of 
acetate  of  lead,  or  a  weak  solution  of  the  acetate  of  lead  in  rose 
water,  or  a  mixture  of  the  acetum  lithargyri  and  cream.  Sometimes 
astringents  are  of  service,  such  as  the  gall  ointment ;  or  narcotics, 
such  as  opium*  or  belladona.  If  these  means  fail,  it  will  be  proper 
to  give  an  anodyne  clyster,  and  apply  fomentations  or  emollient 
poultices  to  the  tumour,  but  every  practitioner  can  tell  how  often 
all  topical  applications  have  disappointed  him.  In  some  cases,  the 
tumour  becomes  slack,  and  subsides  gradually ;  in  other  instances 
it  bursts,  and  more  or  less  blood  is  discharged.  If  the  hemorrhage 
be  moderate,  it  gives  relief;  but  if  profuse,  it  causes  weakness,  and 
must  be  restrained  by  pressure  and  astringents.  Great  pain,  or 
much  hemorrhage,  are  both  apt  to  excite  abortion ;  as  the  former 
is  apt  to  act  by  sympathy  in  the  neighbouring  parts.  Even  in  the 
unimpregnated  state,  internal  piles  are  apt  to  produce  symptoms, 
supposed  to  arise  from  the  womb  or  vagina.  The  rectum-bougie 
in  such  cases  is  useful. 

*  Dr.  Johnston  advises  the  following  ointment  to  be  applied,  and  then  a  poul- 
tice to  be  laid  over  the  tumour.  R.  01.  Amygd.  iji.  01.  Succini  ss  Tr.  Opii.  3'ti. 
M.  System,  p.  125. 


225 

§  10.  AFFECTIONS  OF  THE  BLADDER. 

The  bladder  is  often  affected  by  pregnancy.  In  some  instances, 
like  the  intestines,  it  becomes  more  torpid  than  formerly  ;  so  that 
the  woman  retains  her  water  long,  and  expels  it  with  some  difficul- 
ty, and  in  considerable  quantity  at  a  time.  This  state  requires 
great  attention,  for  retroversion  of  the  uterus  may,  at  a  certain  stage 
of  gestation,  be  readily  occasioned.  There  is  not  much  to  be  done 
with  medicines  in  this  case  ;  for  although  soda,  and  similar  reme- 
dies, sometimes  give  relief,  yet  more  reliance  must  pe  placed  on 
the  regular  efforts  of  the  patient.  Should  these  be  delayed  too 
long,  then  the  catheter  must  be  employed. 

More  frequently  the  bladder  is  rendered  unusually  irritable,  es- 
pecially about  its  neck,  and  the  uretha  participates  in  this  state. 
There  is  also,  in  many  instances,  an  uneasiness  felt  in  the  region 
of  the  bladder  itself.  This  state  requires  a  very  different  treat- 
ment from  the  former,  for  here  it  is  our  object  to  avoid  every  sa- 
line medicine  which  might  render  the  urine  more  stimulating.  Re- 
lief is  to  be  expected  by  taking  away  blood,  giving  small  doses  of 
castor  oil,  and,  occasionally,  the  extract  or  tincture  of  hyoscyamus, 
and  encouraging  the  patient  to  drink  mucilaginous  fluids,  which,  if 
they  do  not  reach  the  bladder  as  mucilage,  at  least  afford  a  bland 
addition  to  the  blood,  from  which  the  urine  is  secreted.  The  state 
of  the  bladder  is  sometimes  productive  of  a  slight  irritation  about 
the  symphysis  of  the  pubis,  rendering  the  articulation  less  firm  and 
more  easily  separated.  In  such  circumstances,  when  the  pubis  is 
tender,  blood-letting  and  rest  are  the  two  principal  remedies. 

A  very  distressing  affection,  which  is  often  conjoined  with  this 
state  of  the  bladder  and  uretha,  but  which  may  also  take  place 
without  it,  is  a  tender  and  irritable  state  of  the  vulva,  producing 
great  itching  about  the  pudendum,  especially  during  the  night,  and 
generally  the  urine  is  felt  very  hot.  This  distressing  condition  is 
often  alleviated  by  blood-letting  and  laxatives ;  and  when  the  itch- 
ing is  great,  a  sponge,  dipped  in  cold  water,  or  in  cold  solution  of 
cerussa  acetata,  should  be  applied.     If  much  fever  exist  the  saline 

julap,  combined  with  a  little  tincture  of  opium,  is  useful 

30 


226 

Incontinence  of  urine  is  not  uncommon  in  the  end  of  gestation, 
and  is  produced  by  the  pressure  of  the  uterus  on  the  bladder,  by 
which  the  urine  is  forced  off  involuntarily,  whenever  the  woman 
coughs  or  moves  quickly  ;  or  at  least  she  cannot  retain  much  of 
it,  being  obliged  to  void  it  frequently,  but  without  strangury.  For 
this  complaint  there  is  no  cure  ;  and  many  consider  it  as  a  favour- 
able omen,  that  the  child's  head  is  resting  on  the  os  uteri.  When 
the  uterus  is  very  pendulous,  some  advantage  may  be  obtained,  by 
supporting  the  belly  with  a  proper  bandage  attached  to  the  shoul- 
ders. 


§  11.  JAUNDICE. 

Connected  with  the  state  of  the  alimentary  canal,  is  the  jaun- 
dice of  pregnant  women.  This  disease  appears  at  an  early  period, 
and  is  preceded  by  dyspeptic  symptoms,  which  generally  increase 
after  the  yellowness  comes  on.  In  some  instances,  the  tinge  is 
very  slight,  and  soon  disappears.  In  other  cases,  the  yellow  co- 
lour is  deep  and  long  continued,  and  the  derangement  of  the  sto- 
mach and  bowels  considerable.  Emetics,  and  other  violent  reme- 
dies, which  are  sometimes  used  in  the  cure  of  the  jaundice,  are 
not  allowable  in  this  case  ;  and,  in  every  instance,  when  young 
married  women  are  seized  with  jaundice,  we  should  be  very  cau- 
tious in  our  prescriptions.  Gentle  doses  of  calomel,  or  of  other 
laxatives,  with  some  light  bitter  infusion,  are  the  most  proper  re- 
medies ;  and  generally  the  complaint  soon  goes  off.  Jaundice 
may  also  take  place  in  the  end  of  gestation  ;  and  in  this  case,  it 
proceeds  most  frequently  from  pressure  on  the  gall  duct.  Some- 
times, however,  it  is  dependent  on  a  disease  of  the  liver  itself, 
which  may  occur  at  any  period  of  gestation,  and  is  marked  by  the 
usual  symptoms.  In  this  case,  the  danger  is  very  great,  and  can 
only  be  averted  by  taking  cautious  measures  for  removing  the  he- 
patic disease. 

§  13.  COLOURED  SPOTS. 

Tn  some  cases,  the  skin  is  partially  coloured  :  the  mouth,  for  in- 


227 

stance,  being  surrounded  with  a  yellow  or  brown  circle,  or  irregu- 
lar patches  of  these  colours  appearing  on  different  parts  of  the  bo- 
dy. This  is  an  affection  quite  independent  of  the  state  of  the  bile, 
and  seems  rather  to  be  connected  with  certain  conditions  of  the 
alimentary  canal.  It  goes  off  after  delivery,  and  does  not  require 
any  peculiar  treatment. 

§  13.  PALPITATION. 

The  thoracic  viscera  not  unfrequently  suffer  during  pregnancy. 
Palpitation  of  the  heart  is  a  very  common  affection,  and  extremely 
distressing.  It  is  a  disease  so  well  known,  that  it  is  needless  here 
to  describe  it ;  but  it  may  not  be  improper  to  observe,  that  women 
themselves  sometimes  mistake  for  it  a  strong  pulsation  of  the  arte- 
ries, at  the  upper  part  of  the  abdomen.  It  may  make  its  attack 
repeatedly  in  the  course  of  the  day  ;  or  only  at  night  before  falling 
asleep  ;  or  at  the  interval  of  two  or  three  days  ;  and  is  very  readi- 
ly excited  by  the  slightest  agitation  of  the  mind.  It  is  generally 
void  of  danger  ;  but,  in  delicate  women,  and  in  those  who  are  dis- 
posed to  abortion,  it  sometimes  occasions  that  event ;  and,  if  long 
continued,  it  may  excite  pulmonic  disease  in  those  who  are  pre- 
disposed to  it.  Absolute  rest,  with  antispasmodics,  are  requisite 
during  the  paroxysm.  Hartshorn,  ether,  and  tincture  of  opium, 
may  be  given,  separately  or  combined.  Roderic  a  Castro  pre- 
scribes a  draught  of  hot  water.  The  attacks  are  to  be  prevented 
by  the  administration  of  tonics,  such  as  tincture  of  muriated  iron  ; 
and  of  fcetids,  such  as  valerian  and  asafcetida.  Fatigue  and  exer- 
tion must  be  avoided,  and  the  mind  kept  tranquil.  If  the  person 
be  plethoric,  head  be  pained,  or  the  face  flushed,  it  is  useful  to 
take  away  a  little  blood.  The  bowels  are  to  be  carefully  kept 
open.  The  diet  must  be  attended  to  ;  for  it  is  often  produced  by 
a  disordered  stomach. 

A  tendency  to  nervous  or  hysterical  diseases  is  to  be  prevented, 
in  those  who  are  liable  to  them,  by  occasional  blood-letting,  the 
use  of  laxatives,  and  camphor,  or  foetids.  Opiates  are  only  to  be 
given  for  the  immediate  relief  of  urgent  symptoms. 


228 


§  14.  SYNCOPE. 

Another  distressing  affection  of  the  heart,  attendant  on  pregnan- 
cy, is  syncope.  This  may  take  place  at  any  period  of  gestation, 
but  is  most  frequent  in  the  three  first  months,  or  about  the  time  of 
quickening.  It  often  occurs  in  those  who  are  otherwise  healthy, 
but  it  also  may  occur  daily  for  some  time  in  those  who  are  weak- 
ened by  a  loose  state  of  the  bowels,  alternating  with  costiveness, 
or  by  want  of  sleep  occasioned  by  toothach.  It  may  succeed  some 
little  exertion,  or  speedy  motion,  or  exposure  to  heat ;  but  it  may 
also  come  on  when  the  person  is  at  perfect  rest.  The  paroxysm 
is  sometimes  complete,  and  of  long  duration ;  at  other  times,  the 
person  does  not  lose  her  knowledge  of  what  is  going  on,  and  soon 
recovers.  A  recumbent  posture,  the  admission  of  cold  air,  or  ap- 
plication of  cold  water  to  the  face,  the  use  of  volatile  salt,  and  the 
cautious  administration  of  cordials,  constitute  the  practice  during 
the  attack.  Should  the  fit  remain  long,  we  must  preserve  the  heat 
of  the  body,  otherwise  a  protracted  syncope  may  end  in  death. 
Those  who  are  subject  to  fainting  fits,  must  avoid  fatigue,  crowded 
or  warm  rooms,  fasting,  quick  motion,  and  agitation  of  the  mind. 
Tonics  are  useful  when  the  system  is  weak,  and  the  bowels  must 
be  regulated. 

There  is  a  species  of  syncope,  that  I  have  oftener  than  once 
found  to  prove  fatal  in  the  early  stage  of  pregnancy,  which  is  de- 
pendent, I  apprehend,  on  organic  affections  of  the  heart,  that  vis- 
cus  being  enlarged,  or  otherwise  diseased,  though  perhaps  so  slight- 
ly as  not  previously  to  give  rise  to  any  troublesome,  far  less  any 
pathognomonic  symptoms.  Although  I  have  met  with  this  fatal 
termination  most  frequently  in  the  early  stage,  I  have  also  seen  it 
take  place  so  late  as  the  sixth  month  of  pregnancy. 

§  15.  DYSPNCEA  AND  COUGH. 

Sudden  attacks  of  dyspnoea  in  those  who  were  previously  heal- 
thy, are  generally  to  be  considered  as  hysterical,  and  are  readily  re- 
moved by  antispasmodics.     There  is,  however,  a  more  obstinate 


229 

and  protracted  symptom,  not  unfrequently  connected  with  preg- 
nancy, namely  cough.  This  may  come  in  paroxysms,  which  are 
generally  severe,  or  it  may  be  almost  constant,  in  which  case  it  is 
short  and  teasing.  Sometimes  a  viscid  fluid  is  expectorated,  but 
more  frequently  the  cough  is  dry.  During  the  attack,  the  head  is 
generally  painful,  and  the  woman  complains  much  of  the  shaking 
of  her  body,  especially  of  the  belly.  All  practical  writers  are  agreed 
with  respect  to  the  danger  of  this  disease,  for  it  is  extremely  apt 
to  induce  abortion  ;  and  it  is  worthy  of  remark,  that  after  the  child 
is  expelled,  the  cough  often  suddenly  ceases.  But  exposure  to  cold 
frequently  brings  it  back;  and  should  there  be  a  predisposition  to 
phthisis,  that  disease  may  be  thus  excited.  Blood-letting  must  be 
early,  and  sometimes  repeatedly  employed  ;  the  bowels  kept  open ; 
and  lozenges,  containing  opium  or  hyoscyamus,  must  be  occasion- 
ally used,  to  allay  the  cough.  A  large  Burgundy  pitch  plaster,  ap- 
plied betwixt  the  shoulders,  is  of  service  ;  or  a  small  blister  over 
the  junction  of  the  cervical  and  dorsal  vertebrae.  Should  abortion 
take  place,  and  the  cough  continue,  tonics,  such  as  myrrh  and 
oxyde  of  zinc,  ought  to  be  administered. 

§  16.  HAEMOPTYSIS  AND  HJEMATEMES1S. 

In  some  instances,  haemoptysis  or  haematemesis  take  place  in 
pregnancy,  especially  in  the  last  months,  and  these  are  very  dan- 
gerous affections.  Blood-letting  is  the  remedy  chiefly  to  be  de- 
pended on  ;  and  afterwards  purgatives  should  be  given  ;  acids  and 
hyoscyamus  may  be  employed  to  allay  irritation.  If  these  means 
do  not  succeed,  the  patient  dies.  Should  the  hemorrhage  take 
place  during  labour,  or  should  pains  come-on  prematurely,  and  the 
os  uteri  dilate,  as  sometimes  happens,  it  will  be  prudent  to  accele- 
rate the  delivery. 


§  17.  HEADACH  AND  CONVULSIONS. 

Headach  is  a  very  alarming  symptom,  when  it  is  severe,  con- 
stant, and  accompanied  with  symptoms  of  plethora.     If  the  eye 


230 

be  dull  or  suffused,  and  the  head  giddy,  especially  when  the  pa- 
tient stoops  or  lies  down,  with  a  sense  of  heaviness  over  the  eyes, 
or  within  the  skull,  great  danger  is  to  be  apprehended,  particularly 
if  she  be  far  advanced  in  her  pregnancy.  This  is  still  more  the 
case,  if  she  complain  of  ringing  in  the  ears,  and  see  flashes  of  fire ; 
or  have  indistinct  vision.  In  such  circumstances  she  is  seized  either 
with  apoplexy  or  convulsions.  These  diseases  are  to  be  prevented 
by  having  immediate  recourse  to  blood-letting  and  purgatives;  and 
the  same  remedies  are  useful,  if  either  one  or  other  of  these  dis- 
eases have  already  taken  place.  The  quantity  of  blood  which  is 
to  be  detracted,  must  be  determined  by  the  severity  of  the  symp- 
toms, the  habit  of  the  patient,  and  the  effect  of  the  evacuation ; 
but,  generally,  moderate  evacuation  will  prevent,  whilst  very  co- 
pious depletion  is  requisite  to  cure  these  diseases.  If  the  headach 
be  accompanied  with  oedema,  the  digitalis  is  a  useful  addition  to 
the  practice.  I  shall  not  at  present  enter  more  minutely  into  the 
treatment  of  convulsions.  I  shall  only  remark,  that  the  first  thing 
to  be  done  is  to  detract  blood  from  a  vein;  next,  the  bowels  are  to 
be  immediately  opened  by  a  clyster,  and  then  a  purgative  is  to  be 
administered. 

If  the  patient  be  seized  with  apoplexy,  there  is  seldom  any  at- 
tempt made  to  expel  the  child,*  and,  in  my  own  practice,  I  have 
never  known  that  event  take  place.  In  eclampsia,  on  the  contrary, 
if  the  paroxysm  be  protracted,  there  is  generally  an  effect  pro- 
duced on  the  uterus ;  its  mouth  opens,  and  the  child  may  be  ex- 
pelled, if  the  patient  be  not  early  cut  off  by  a  fatal  coma.  When- 
ever expulsive  effects  come  on,  we  must  conduct  the  labour  accord- 
ing to  rules  hereafter  to  be  noticed.  In  some  instances,  palsy  either 
succeeds  an  apoplectic  attack,  or  follows  headach  and  vertigo. 
This  disease  does  not  commonly  go  off  until  delivery  have  taken 
place;  but  it  may  be  prevented  from  becoming  severe,  by  mild 
laxatives  and  light  diet;  and,  after  the  woman  recovers  from  her 
labour,  the  disease  gradually  abates,  or  yields  to  appropriate  re- 
medies. 

All  headachs,  however,  do  not  forebode  these  dismal  events,  for 

"  Mr.  Wilson's  case  is  an  exception  to  this.    Vide  Med.  Facts,  Vol.  v.  p.  96. 


231 

often  they  proceed  from  the  stomach,  and  evidently  depend  on 
costiveness,  dyspepsia,  or  nervous  irritation.  These  are  generally 
periodical,  accompanied  with  a  pale  visage ;  they  feel  more  ex- 
ternal than  the  former,  and  are  often  confined  to  one  side  of  the 
head.  They  are  attended  with  acidity  in  the  stomach,  eructations, 
and  sometimes  considerable  giddiness,  or  slight  sickness,  with 
bitter  taste  in  the  mouth.  They  are  relieved  by  the  regular  exhi- 
bition of  laxatives,  by  sleep,  the  moderate  use  of  volatiles,  and  the 
application  of  ether  externally. 

Hysterical  convulsions  are  not  uncommon  during  gestation,  and 
more  especially  during  the  first  four  months.  They  occur  in  irri- 
table habits,  or  in  those  who  are  naturally  disposed  to  syncope,  or 
who  have  been  exhausted  by  any  pain,  depriving  them  of  rest, 
or  by  alvine  discharges.  They  are  distinguished  by  the  face 
usually  being  pale  during  the  attack,  the  countenance  is  very  little 
distorted,  there  is  no  foam  issuing  from  the  mouth,  the  patient  for 
a  time  lies  as  in  a  faint,  and  then  has  convulsive  motions,  or 
screams  and  sobs,  and  the  fit  generally  is  terminated  by  shedding 
tears.  The  treatment,  in  the  first  instance,  consists  in  adminis- 
tering antispasmodics,  particularly  opiates  and  volatile  foetids.  Af- 
terwards, the  returns  are  to  be  prevented  by  bringing  the  bowels 
into  a  correct  state,  and  keeping  them  so.  The  exercise  is  to 
be  gentle,  but  taken  regularly.  The  diet  mild,  but  nourishing. 
Sleep  is  to  be  procured,  if  necessary,  by  opiates;  and  tonic  medi- 
cines, with  the  assistance  of  ammoniated  tincture  of  valerian,  must 
complete  the  cure.  If,  however,  there  be  a  feeling  of  fulness 
about  the  head,  or  weight,  or  headach,  it  is,  even  in  spare  habits, 
of  service  to  take  away  a  little  blood. 


§  18.  TOOTH  AC  H. 

Toothach  not  unfrequently  attends  pregnancy,  and,  sometimes, 
is  a  very  early  symptom  of  that  state.  The  tooth  may  be  sound 
or  diseased,  but,  in  neither  case,  ought  we  to  extract  it  in  the  early 
months,  if  it  be  possible  to  avoid  the  operation.  I  have  known  the 
extraction  followed  in  a  few  minutes  bv  abortion.     Blood-letting 


232 

frequently  gives  relief,  and,  sometimes,  a  little  cold  water  taken 
into  the  mouth  abates  the  pain.  In  other  cases,  warm  water  gives 
more  relief. 

§  19.  SALIVATION. 

Salivation  is,  with  some  women,  a  mark  of  pregnancy.  It  has 
been  supposed  that  there  is  a  sympathy  existing  between  the  pan- 
creas and  salivary  glands,  and  that  the  phlegm  ejected  by  vomiting 
proceeded  from  the  former,  whilst,  in  many  instances,  the  latter 
yielded  an  increased  quantity  of  viscid  saliva.  This  is  a  symptom 
which  scarcely  demands  any  medicine,  but,  when  itdoe6,  mild  lax- 
atives are  the  most  efficacious. 

§  20.  MASTODYN1A. 

Pain  and  tension  of  the  mammae  frequently  attend  gestation,  and 
these  symptoms  are  often  very  distressing.  If  the  woman  have  for- 
merly had  a  suppuration  of  one  mamma,  that  breast  is  generally 
most  painful,  and  she  is  afraid  of  abscess  again  forming.  In  other 
instances,  the  pain,  being  accompanied  with  increased  hardness  of 
the  breast,  produces  apprehension  of  cancer.  These  fears  are  ge- 
nerally groundless ;  but  if  suppuration  do  take  place,  it  is  to  be 
treated  on  general  principles.  Blood-letting  often  relieves  the  un- 
easy feeling  in  the  breast,  which  is  also  mitigated  by  gentle  friction 
with  warm  oil.  Nature  often  gives  relief,  by  the  secretion  of  a  se- 
rous fluid  which  runs  out  from  the  nipple ;  but  if  this  be  much  en- 
couraged by  suction,  Chambon  remarks,  that  the  foetus  may  be  in- 
jured. This,  however,  is  so  far  from  being  always  the  case,  that 
many  women,  who  conceive  during  lactation,  continue  to  nurse  for 
some  months,  without  detriment  to  the  foetus.  The  discharge  is 
in  some  instances  so  great  about  the  seventh  month,  or  later,  as  to 
keep  the  woman  very  uncomfortable.  The  diet  in  this  case  should 
be  dry. 

The  sudden  abatement  of  the  tension,  and  fulness  of  the  breasts, 
with  a  diminution  of  size,  are  unfavourable  circumstances,  indicat- 
ing either  the  death  of  the  child,  or  a  feeble  action  of  the  womb. 


233 


§  21.  (EDKMA. 

In  the  course  of  gestation,  the  feet  and  legs  very  generally  be- 
come cedematous;  and  sometimes  the  thighs  and  labia  pudendi  par- 
ticipate in  the  swelling.  The  swelling  is  by  no  means  proportioned 
always  to  the  size  of  the  womb,  for,  as  has  been  remarked  by  Pu- 
zos, those  who  have  the  womb  unusually  distended  with  water, 
and  those  who  have  twins,  have  frequently  very  little  cedema  of  the 
feet.  This  disease  is  partly  owing  to  the  pressure  of  the  uterus, 
but  it  also  seems  to  be  somewhat  connected  with  the  pregnant  state, 
independent  of  pressure  ;  for  in  some  instances  the  cedema  is  not 
confined  to  the  inferior  extremities,  but  affects  the  whole  body. 
A  moderate  degree  of  cedema,  going  off  in  a  recumbent  posture,  is 
so  far  from  being  injurious,  that  it  is  occasionally  remarked,  that 
many  uneasy  feelings  are  removed  by  its  accession ;  but  a  greater 
and  more  universal  effusion  indicates  a  dangerous  degree  of  irrita- 
tion. In  ordinary  cases,  no  medicine  is  necessary  except  aperients; 
but,  when  the  cedema  is  extensive  or  permanent,  remaining  even 
after  the  patient  has  been  for  several  hours  in  bed,  it  may  be  at- 
tended with  unpleasant  or  dangerous  effects,  such  as  convulsions ; 
or,  it  may  predispose  to  puerperal  diseases;  we  must  therefore  les- 
sen it  by  means  of  those  agents  which  alleviate  the  other  diseases 
of  pregnancy,  namely  blood-letting  and  purgatives.  These  means 
are  always  proper,  and  are  never  to  be  omitted,  unless  the  strength 
be  much  reduced  ;  in  which  case,  we  only  employ  the  purgatives 
and  cordials  prudently,  with  acetate  of  potash,  or  sweet  spirit  of 
nitre.  Diuretics,  generally,  are  not  successful,  and  many  of  them, 
if  given  liberally,  tend  to  excite  abortion.  Friction  relieves  the 
feeling  of  tension. 

<j  22.  ASCITES. 

Ascites  may,  like  cedema,  be  excited,  in  consequence  of  some 
condition  connected  with  gestation,  or  mav  bo  independent  of  it. 

HI 


234 

arising  from  some  of  the  ordinary  causes  of  dropsy,  especially  from 
a  disease  of  the  liver.  In  the  last  case,  medicine  has  seldom  much 
effect  in  palliating  or  removing  the  disease;  and  the  woman  usually 
dies,  within  a  week  or  two  after  her  delivery,  whether  that  have 
been  premature,  or  delayed  till  the  full  time.  When  ascites  is  not 
occasioned  by  hepatic  disease,  and  appears  for  the  first  time  dur- 
ing gestation,  it  is  generally  connected  with  the' cedematous  state 
above  mentioned,  and  seldom  comes  on  until  the  woman  has  been 
at  least  three  months  pregnant.  If  it  be  not  attended  with  other 
bad  symptoms,  such  as  headach,  feverishness,  drowsiness,  &c.  it 
abates  and  goes  off,  a  little  before,  or  soon  after  delivery,  which  is 
oiten  premature.  But  in  other  instances  it  increases,  and  from  the 
distention  produced,  very  great  difficulty  of  breathing  is  occasioned. 
I  have  seen  diuretics  given  very  freely  in  these  cases,  but  most 
frequently  without  any  benefit.  On  this  account,  and  also  from 
the  danger  of  these  exciting  abortion,  or  premature  labour,  I  am 
inclined  to  dissuade  from  their  use,  except  in  urgent  cases.  Then 
the  mildest  ought  to  be  employed,  such  as  cream  of  tartar,  juniper 
tea,  acetate  of  pot-ash,  &c.  If  any  of  these  produce  much  irrita- 
tion of  the  urinary  organs,  they  must  be  exchanged  for  others. 
Purgatives  and  blood-letting  are  more  useful ;  for  this  is  an  acute 
disease,  more  easily  remedied  by  depletion  than  by  any  other 
means.  If,  in  spite  of  this  treatment,  the  swelling  increase,  para- 
centesis must  be  performed. 

Ascites  may  have  existed  previously  to  pregnancy,  and  the  two 
causes  combined,  may  produce  a  very  great  enlargement  of  the 
belly.  In  this  case,  the  uterus  may  be  felt  through  the  teguments, 
sometimes  very  much  compressed,  as  if  the  child  lay  across.  Mild 
diuretics  tend  to  keep  the  disease  at  bay  ;  and  if  the  distention  be 
very  great,  especially  at  an  early  stage,  my  experience  leads  me 
to  conclude,  that  after  quickening,  a  great  part  of  the  fluid  may  be 
drawn  off  safely,  provided,  during  the  operation  and  afterwards, 
the  abdomen  be  carefully  and  uniformly  supported  by  a  bandage. 
It  is  useful  to  know  this,  as  the  distention  is  sometimes  so  great, 
that  life  could  not  go  on,  without  much  distress,  till  the  end  of 
gestation.     The  operation,  I  think,  is  more  apt  to  be  succeeded 


235 

by  labour,  it' performed  in  the  last  month,  than  earlier.^J  In  all 
cases  where  the  patient  is  weak,  we  must  take  great  care  that  the 
puncture  be  correctly  closed :  for  if  its  lips  inflame  instead  of  ad- 
hering, fatal  peritonitis  is  the  invariable  result. 

§  23.  REDUNDANCE  OF  L1QUOK  AMNII. 

When  the  liquor  amnii  is  in  too  great  quantity,  much  inconve- 
nience is  produced,  and  not  unfrequently  the  child  perishes.  This 
disease  is  known,  by  the  woman  being  unusually  large  at  an  early 
period  of  gestation,  for  generally  by  the  seventh  month,  she  is  as  big 
as  she  ought  to  be  in  the  ninth.  It  is  distinguished  from  ascites, 
by  the  motion  of  the  child  being  felt,  though  obscurely,  by  the 

fzj  Instances  have  occurred,  where  in  cases  of  ascites  combined  with  preg- 
nancy, the  operation  of  paracentesis  has  been  performed,  although  this  is  a 
practice  by  no  means  to  be  commended.  In  the  eighth  Vol.  of  the  London 
Med.  Facts  and  Observations,  there  is  a  case  related  by  Mr.  Simmons,  of  a  preg- 
nant woman  with  symptoms  of  ascites  being  twice  tapped,  first,  in  the  second 
month  of  pregnancy,  when  fourteen  quarts  of  water  were  drawn  off,  and  the 
second  time,  when  five  months  advanced,  when  only  a  few  ounces  of  blood  fol- 
lowed the  withdrawing  of  the  trocar  ;  at  the  full  time  she  was  delivered  of  a 
healthy  child,  having  suffered  no  inconvenience  from  the  operation. 

Another  case  is  related  in  the  seventh  Vol.  of  the  London  Med.  and  Phys. 
Journal,  by  Dr.  Vieusseux,  of  Geneva,  where  a  woman  in  the  fifth  month  of 
pregnancy  was  tapped,  but  it  appears  that  the  consequence  of  this  operation 
was  an  abortion,  although  the  patient  soon  recovered.  Both  these  cases  are  re- 
lated by  the  gentlemen  under  whose  observation  they  fell,  to  prove  that  the 
paracentesis  has  been  performed,  and  even  the  uterus  perforated,  [which  they 
suppose  was  the  case  in  both  these  instances,]  whithout  material  injury  to  the 
patient. 

In  the  same  work  is  related  a  case  of  a  woman,  who  was  tapped  no  less  than 
five  times  during  pregnancy  :  at  the  full  period  she  was,  notwithstanding,  de- 
livered of  a  fine  child,  and  recovered  completely  from  the  puerperal  state. 

These  cases  prove,  how  much  the  system  will  sometimes  suffer  with  impu- 
nity, but  at  the  same  time  we  must  acknowledge,  that  it  is  best  not  to  presume 
too  far  on  the  preservative  energies  of  nature. 

Sometimes  pregnancy  has  be^en,  from  gross  inaccuracy,  mistaken  for  dropsy, 
and  the  paracentesis  been  performed  with  a  fatal  effect;  the  patient  in  one  in- 
stance fainting,  and  expiring  almost  instantaneously.  Upon  examination  sfter 
death,  it  was  found  that  the  trocar  had  not  only  perforated  the  uterus,  but  had 
also  penetrated  the  fcrtus' 


236 

mother,  and  the  breasts  enlarging.  Per  vaginam  we  can  ascer- 
tain, that  the  uterus  contains  a  substance,  which  alternately  recedes 
and  descends  as  the  finger  strikes  on  the  lower  part  of  the  womb. 
This  is  to  be  considered  as  a  dropsical  affection  of  the  ovum,  but 
the  health  of  the  woman  seldom  suffers  so  much  as  in  ascites  ;  the 
tongue,  however,  is  white,  and  the  urine  is  diminished  in  quantity. 
The  legs  are  less  apt  to  swell  than  in  a  common  pregnancy.  The 
distension  may,  in  the  advanced  stage,  prove  troublesome.  When 
the  quantity  of  water  is  greatly  increased,  the  child  is  seldom  kept 
till  the  full  time,  but  is  generally  expelled  in  the  eighth  month,  or 
sooner,  and  the  labour  is  apt  to  be  accompanied  or  succeeded  by 
uterine  hemorrhage.  In  some  instances,  the  child  occupies  the 
upper  part  of  the  uterus,  and  the  water  the  under,  at  least  during 
labour.  Twice  in  the  same  woman,  in  succeeding  pregnancies,  I 
found  the  child  contained  in  the  upper  part  of  the  uterus,  and  em- 
braced by  it  as  if  it  were  in  a  cyst,  whilst  several  pints  of  water 
lay  between  it  and  the  os  uteri.  When  the  water  came  away, 
filling  some  basins,  then  the  child  descended  to  the  os  uteri,  but 
was  born  dead,  with  the  thighs  turned  firmly  up  over  the  abdomen, 
and  other  marks  of  deformity. 

We  know  the  water  to  be  contained  in  the  uterus,  and  not  in 
the  abdominal  cavity,  by  feeling  the  shape  and  firmness  of  the 
Uterus,  and  by  the  greater  obscurity  of  the  fluctuation.  In  ascites, 
complicated  with  pregnancy,  the  fluid  is  more  distinct,  and  the 
shape  of  the  uterus  cannot  be  perceived  till  after  tapping.  This  is 
a  disease  of  the  ovum,  and  not  of  the  mother,  for  even  the  foetus 
itself  is  often  malformed,  or  at  least  blighted.  The  affection  in  toto 
may  be  considered  as  a  species  of  monstrous  conception.  Some 
particular  condition  of  the  parent  may,  however,  in  certain  cases, 
occasion  it.  For  instance,  it  may  be  connected  with  a  syphilitic 
taint  in  either  the  father  or  mother;  or  with  some  less  obvious 
cause  impairing  the  action  of  the  womb,  but  not  directly  producing 
a  miscarriage;  with  lunacy  or  idiotism ;  or  with  a  state  of  general 
or  uterine  debility ;  or  with  an  original  imperfection  of  the  ova  in 
the  ovarium  :  for  a  woman  may,  without  any  apparent  cause,  have 
repeatedly  this  kind  of  pregnancy.  All  of  these  causes  do  not  ope- 
rate uniformly  to  the  same  extent ;  but  the  foetus  suffers  in  propor- 


lion  to  their  operation.  It  is  either  horn  very  feeble  and  languid, 
and  is  reared  with  difficulty,  or  it  dies  almost  immediately,  or  it 
perishes  before  labour  commences ;  and  this  is  generally  the  case 
when  the  diseased  state  exists  to  any  great  degree.  The  period 
of  the  child's  death  is  usually  marked  by  a  shivering  fit,  and  ces- 
sation of  motion  in  utcro,  at  the  same  time  that  the  breasts  become 
flaccid.  Afterwards  irregular  pains  come  on,  with  or  without  a 
watery  discharge.  Sometimes  the  woman  is  sick  or  feverish  for  a 
few  days  before  labour  begins. 

If  the  liquor  amnii  be  not  increased  greatly  beyond  the  usual 
quantity,  the  woman  may  go  the  full  time,  but,  from  the  distention 
of  the  uterus,  is  apt  to  have  a  lingering  labour. 

Tonics,  the  cold  bath,  dry  diet,  with  occasional  venesection,  and 
the  use  of  laxatives,  during  pregnancy,  may  be  of  service,  but 
frequently  fail.  Diuretics  do  no  good.  A  course  of  mercury  con- 
ducted prudently,  previous  to  conception,  is  the  only  remedy, 
when  we  suspect  a  syphilitic  taint.  It  may  be  necessary  to  pre- 
scribe it  to  both  parents.  When  it  proceeds  from  some  more 
latent  cause,  I  think  it  is  useful  for  preventing  a  repetition  of  the 
disease,  to  make  the  mother  nurse,  even  although  her  child  be 
dead.     Mercury  ought  also  to  be  tried. 

When  the  distention  produces  much  distress,  it  has  been  pro- 
posed to  draw  off  the  water  by  the  os  uteri;  or  this  has  been  done 
in  one  case  by  the  common  operation  of  paracentesis,  the  woman 
surviving,  and  labour  taking  place  on  the  twenty-first  day.*  This 
practice  is,  however,  generally  improper,  and  is  seldom  requisite; 
pains  usually  coming  on  whenever  the  symptoms  become  severe. 
When  the  os  uteri  is  considerably  dilated  by  the  pains,  it  may  be 
proper  to  rupture  the  membranes,  as  has  been  advised  by  Puzos. 

*  Vide  case  by  Noel  Desmarais,  in  Recueil  Period.  Tom.  VI.  p.  349.  M. 
Baudelocque  gives  a  memoir  on  this  subject,  in  the  same  volume.  Scarpa, 
also,  seems  to  defend  the  paracentesis,  but  it  is  impossible  to  discover  any  supe- 
riority this  lias  over  the  safer  mode  of  introducing  a  catheter  or  tube,  by  the  os 
uteri. 


238 


§  24.  WATERY  DISCHARGE. 

Discharges  of  watery  fluid  from  the  vagina  are  not  unfrequent 
during  pregnancy,  and  generally  depend  upon  secretion  from  the 
glands  about  the  cervix  uteri.  It  has  been  supposed,  that,  in  every 
case  they  proceeded  from  this  cause,  or  from  the  rupture  of  a 
lymphatic,  or  the  evacuation  of  a  fluid  collected  between  the  cho- 
rion and  amnion,  or  the  water  of  a  blighted  ovum,  in  a  case  of 
twins ;  for  in  every  instance,  where  the  liquor  amnii  has  been  arti- 
ficially evacuated,  labour  has  taken  place.  But  we  can  suppose, 
that  the  action  of  gestation  may,  in  some  women,  be  so  strong,  as 
not  to  be  interrupted  by  a  partial  evacuation  of  the  liquor  amnii. 
Even  granting  the  water  to  be  collected  exterior  to  the  chorion, 
there  must  be  a  strong  tendency  to  excite  labour,  if  the  quantity 
discharged  be  great;*  and  if  the  uterus  can  resist  this,  it  may  also 
be  unaffected  by  the  evacuation  of  liquor  amnii.  I  have  known 
instances,  where,  after  a  fright  or  exertion,  a  considerable  quantity 
of  water  has  been  suddenly  discharged,  with  subsidence  of  the 
abdominal  tumour,  or  feeling  of  slackness ;  and  even  irregular  pains 
have  taken  place,  and  yet  the  woman  has  gone  to  the  full  time.f 
These  prove,  as  far  as  the  nature  of  the  case  will  admit  of  proof, 
that  the  water  has  been  evacuated.  Sometimes  only  one  discharge 
has  taken  place,  but  oftener  the  first  has  been  followed  by  others; 
and  these  are  often  tinged  with  blood.  The  aperture  seems  to 
heal,  if  gestation  go  on;  for,  during  labour,  a  discharge  of  water 
takes  place.  Much  more  frequently  labour  does  take  place.  Even 
when  the  discharge  proceeds  only  from  the  vessels  or  glands  about 
the  os  uteri,  if  the  woman  be  not  careful,  a  hemorrhage  may  take 

*  Vide  Dr.  Alexander's  case,  in  Med.  Comment.  Vol.  HI.  p.  187. 

f  Dr.  Pentland  relates  a  very  distinct  case,  where  the  liquor  was,  in  the  third 
or  fourth  month,  discharged  in  a  fit  of  coughing.  The  belly  fell,  but  she  still 
went  on  to  the  full  time,  and  had  a  good  labour,  Dublin  Med.  and  Phys.  Essays, 
No.  I.  art.  3. — I  have  known  a  discharge  of  water  take  place  at  short  intervals, 
for  some  weeks;  and  then  the  funis  umbilicalis  protruded,  without  any  exertion, 
or  any  pains  to  rupture  the  membranes,  which  is  a  demonstration  that  the  mem- 
branes had  been  previously  open,  and  that  the  discharge  of  liquor  did  not  speed- 
ily excite  labour. 


239 

place,  followed  by  labour.  This  is  most  likely  to  happen  if  there 
have  been  a  copious  discharge. 

The  practice,  in  these  cases,  is  to  confine  the  patient  for  some 
time  to  bed.  An  anodyne  ought  also  to  be  given,  and  may  be  re- 
peated occasionally,  if  she  be  affected  either  with  irregular  pain, 
or  nervous  irritation ;  previous  venesection  often  renders  this  more 
useful.  The  bowels  are  to  be  kept  open.  If  we  suppose  the  dis- 
charge to  be  from  the  glands  or  vessels  about  the  os  uteri,  we  may, 
with  advantage,  inject  some  astringent  fluid,  such  as  a  solution  of 
sulphate  of  alumine. 

It  sometimes  happens,  that  a  large  hydatid  is  lodged  between 
the  ovum  and  the  os  uteri,  and  it  may  be  expelled  several  weeks 
before  parturition.  If  care  be  not  taken,  this  may  be  followed  by 
hemorrhage. 


§  25.  VARICOSE  VEINS. 

Varicose  tumours  sometimes  appear  on  the  legs.  They  are  not 
dangerous,  but  are  often  painful.  By  pressure,  they  can  be  re- 
moved; but  I  am  not  sure  that  it  is  altogether  safe  to  apply  a  ban- 
dage round  the  legs,  so  tight  as  to  prevent  their  return.  It  is  bet- 
ter, in  ordinary  cases,  to  do  nothing  at  all ;  but  where  there  is  much 
pain,  a  recumbent  posture  and  moderate  pressure  give  relief. 


§  26.  MUSCULAR  PAIN. 

From  the  distention  of  the  abdominal  muscles,  pain  may  be  pro- 
duced, either  about  the  extremities  of  the  recti  muscles,  or  the  ori- 
gins of  the  oblique  or  transverse  muscles.  These  pains  are  not 
dangerous,  but  give  unnecessary  alarm  if  the  cause  be  not  known , 
It  is  impossible  to  remove  them,  but  they  may  be  mitigated  by 
anodyne  embrocations.  If  the  pain  be  severe  along  the  edge  ot 
the  ribs,  relief  may  be  obtained  by  applying  round  the  upper  part 
of  the  abdomen  a  narrow  band  of  leather,  spread  with  adhesive 
plaister. 

There  is  another  cause  of  pain,  which  sometimes  affects  these 


240 

muscles,  but  oficner  those  about  the  pelvis  and  hips.  This  seems 
to  consist  in  a  diminished  power  of  the  muscles,  in  consequence  of 
the  uterine  action,  and  thus  the  fibres  are  not  capable  of  the  same 
exertion  as  formerly.  A  long  walk,  or  some  little  fatigue,  may 
produce  such  an  effect,  as  to  render  them  painful  for  a  long  time : 
or  even  without  any  unusual  degree  of  motion,  they  may  ache,  and 
produce  the  sensation  of  weariness.  These  pains  have  been  sup- 
posed to  be  most  frequent  when  the  woman  has  twins  ;  but  this  is 
far  from  being  a  general  rule.  They  may  occasion  an  apprehen- 
sion that  she  is  going  to  miscarry.  Rest  is  the  principal  remedy ; 
but  if  they  be  severe,  relief  may  often  be  obtained  by  venesection. 
Pain  in  the  side,  particularly  the  right  side,  is  sometimes,  at  an 
advanced  period  of  gestation,  both  muscular,  and  also  connected 
with  the  state  of  the  bowels,  especially  of  the  colon.  It  is  frequentr 
ly  most  severe,  and  may  be  rendered  still  more  distressing,  by  be- 
ing combined  with  violent  heartburn,  or  water-brash.  It  comes 
on  chiefly  at  night,  and  instead  of  being  relieved  by  lying  down, 
is  often  increased  on  going  to  bed.  It  is  usually  accompanied 
with  much  motion  of  the  child.  Venesection  sometimes  gives  re- 
lief, but  generally  more  advantage  is  derived  from  rubbing  with 
anodyne  balsam,  attending  to  the  state  of  the  bowels,  and  regulat- 
ing the  diet.  Although  the  pain  be  very  severe,  it  seldom  brings 
on  labour.  In  certain  cases  there  is  a  complication  of  pleuritic 
pain  of  the  side,  spasm  of  the  ureter,  and  some  portion  of  the  in- 
testines, and  sensibility  of  part  of  the  abdominal  muscles.  Blood- 
letting and  purgatives,  followed  by  anodynes,  and  rubefacient  ap- 
plications, form  the  practice. 

§  27.  SPASM  OF  URETEK. 

Spasm  of  the  ureter,  or  some  violent  nephritic  affection,  may 
occur  during  gestation.  The  pain  is  severe,  the  pulse  slow  and 
soft,  and  the  stomach  often  filled  with  wind.  The  symptoms  are 
attended  with  distressing  strangury,  and  if  not  soon  removed,  may 
cause  premature  labour.  Decided  relief  is  obtained  by  giving  a 
saline  clyster,  and  after  its  operation,  injecting  eighty  drops  of 


241 

laudanum  mixed  with  a  little  starch.     A  sinapism  is  to  be  applied 
to  the  loin,  and  if  these  means  fail,  blood  must  be  taken  away. 

§  28.  CRAMP. 

Spasms  in  the  inferior  extremities  are  often  very  distressing. 
These  may  come  on  suddenly,  but  occasionally  they  are  preceded 
by  a  sense  of  coldness,  and  accompanied  with  a  feeling  of  heat. 
They  are  removed  by  change  of  posture,  and  gentle  friction. 
They  have,  by  some,  been  thought  to  indicate  a  wrong  presenta- 
tion of  the  child ;  but  this  opinion  is  not  supported  by  experience. 
They  proceed  from  the  pressure  of  the  uterus  on  the  nerves  in  the 
pelvis. 

§  29.  SPASM  OP  THE  UTERUS. 

The  gravid  uterus  itself,  at  various  periods  of  gestation,  is  liable 
to  be  affected  with  spasm.  This  is  marked  by  great  pain  in  the 
region  of  the  uterus,  subject  to  exacerbations,  but  never  going  en- 
tirely off.  It  is  presently  succeeded  by  inflammation,  marked  by 
frequency  of  pulse,  thirst,  heat  of  skin,  sometimes  sickness,  consti- 
pation, more  or  less  tenderness  of  the  hypogastric  region,  with  se- 
vere pain  stretching  to  one  or  both  groins,  and  occasionally  in  the 
back.  In  every  instance  I  have  known,  the  ovum  has  been  ex- 
pelled, and  in  some,  the  patient  has  sunk  soon  afterwards.  The 
practice,  even  when  the  case  is  clearly  spasmodic,  consists  in  de- 
tracting blood,  and  after  opening  the  bowels,  giving  powerful  doses 
of  opium,  either  by  the  mouth,  or  as  clysters  ;  and  this  remedy 
must  be  repeated  as  often  as  necessary.  When  inflammation  has 
taken  place,  the  detraction  of  blood  must  be  pushed  farther,  the 
semicupium  employed,  stools  procured,  and  anodyne  clysters  ad- 
ministered. When  abortion  takes  place,  the  strength  must  be 
supported,  and  irritation  allayed  by  the  free  use  of  opium  ;  but  the 
patient  is  in  a  dangerous  state. 

32 


242 


§  30.  DISTENTION  OF  THE  ABDOMEN. 

In  a  first  pregnancy,  the  abdominal  muscles  generally  preserve 
a  greater  degree  of  tension  than  they  do  afterwards  ;  and  therefore 
the  belly  is  not  so  prominent  as  in  succeeding  pregnancies.  Some- 
times the  muscles  and  integuments  yield  so  readily  to  the  uterus, 
that  it  falls  very  much  forward,  producing  a  great  prominence  in 
the  shape,  inconvenience  from  the  pressure  on  the  bladder,  and 
pain  in  the  sides  from  the  increasing  weight  of  the  projecting  ute- 
rus. In  such  cases,  benefit  may  be  derived  from  supporting  the 
abdomen  with  a  bandage  connected  with  the  shoulders.  In  other 
instances,  the  muscles  and  integuments  do  not  yield  freely,  but  the 
belly  is  hard  and  tense  ;  the  patient  feels  shooting  pains  about  the 
abdomen,  and  sometimes  miscarries.  This  state  is  relieved  by 
blood-letting  and  tepid  fomentations.  When  the  skin  does  not 
distend  freely,  and  becomes  tender  and  fretted,  or  when  these  ef- 
fects are  produced  by  very  great  distention,  benefit  is  derived  from 
fomenting  with  decoction  of  poppies,  and  afterwards  applying  a 
piece  of  soft  linen,  spread  very  thinly  with  some  emollient  oint- 
ment. 

There  is  sometimes  a  disposition  to  distend  unequally,  so  that 
one  side  yields  more  than  the  other,  or  even  part  of  one  side,  or 
one  muscle  more  than  the  rest,  producing  a  peculiar  shape.  This 
is  attended  with  no  inconvenience. 

§  31.  HERNIA. 

It  is  very  usual  for  the  navel  of  pregnant  women  to  become  pro- 
minent even  at  an  early  stage.  In  some  instances,  such  a  change 
is  produced,  as  to  allow  the  intestine  or  omentum  to  protrude, 
forming  an  umbilical  hernia ;  or  if  the  woman  have  been  formerly 
subject  to  that  disease,  pregnancy  tends  to  increase  it,  whilst,  on 
the  other  hand,  the  intestines  being  soon  raised  up  by  the  ascend- 
ing uterus,  inguinal  and  femoral  hernia?  are  not  apt  to  occur,  or  are 
even  removed  if  they  formerly  existed.  Umbilical  hernia  ought 
to  be  either  kept  reduced  by  a  proper  bandage,  or  at  least  prevent- 


243 

cd,  by  due  support,  from  increasing ;  and  during  delivery,  we 
must  be  careful  that  the  intestine  be  not  forcibly  protruded,  as  it 
might  be  difficult  to  replace  it.  After  delivery,  a  truss  must  be  ap- 
plied with  spring  wings,  which  come  round  by  the  side  of  the  belly. 

In  some  cases,  during  gestation,  the  fibres  of  the  abdominal  mus- 
cles separate,  so  that  a  ventral  hernia  is  formed.  The  same  cir- 
cumstance may  take  place  during  parturition;  and  the  laceration  is 
sometimes  so  large,  that  afterwards,  whenever  the  muscles  contract, 
as,  for  instance,  in  the  act  of  rising,  a  quantity  of  intestine  is  forced 
out,  forming  a  hard  tumour  like  a  child's  head.  It  is  necessary  in 
this,  and  in  all  other  cases  of  large  hernia,  to  be  careful  that  com- 
pression be  applied  immediately  after  delivery,  and  also  during 
the  expulsion  of  the  child.  By  neglecting  this,  syncope  and  uterine 
hemorrhage  have  been  occasioned. 

Iiernise  of  the  bladder  should  always  be  reduced  in  the  com- 
mencement of  labour,  for  it  may  interfere  with  the  process  of  par- 
turition, or  the  bladder  may  be  exposed  to  injury. 

§  32.  DESPONDENCY. 

It  is  not  uncommon  to  find  women  very  desponding  during  preg- 
nancy, and  much  alarmed  respecting  the  issue  of  their  confine- 
ment. This  apprehensive  state  may  be  the  consequence  of  acci- 
dents befalling  others  in  parturition ;  but  not  unfrequently  it  pro- 
ceeds from  a  peculiar  state  of  mind,  dependent  on  gestation.  Some, 
who  at  other  times  enjoy  good  spirits,  become  always  melancholy 
during  pregnancy,  whilst  others  suffer  chiefly  during  lactation. 
Little  can  be  done  by  medicine,  except  to  obviate  all  cause  of  dis- 
ease, or  uneasiness  of  the  body ;  the  mind  is  to  be  cheered  and 
supported  by  those  who  have  most  influence  with  the  patient. 

§  33.  RETROVERSION  OF  THE  UTERUS. 

Retroversion  of  the  uterus  was  described,  but  not  explained,  by 
iEtius,  Rod.  a  Castro,  Mauriceau,  and  La  Motte,  and  afterwards 
demonstrated  by  Gregoire,  and  his  pupil  Levret,  but  was  in  this 


244 

country  first  accurately  illustrated  by  Dr.  Hunter,  in  1754.  It  is 
an  accident  which  is  always  attended  with  painful,  and  sometimes 
fatal  consequences,  chiefly  owing  to  the  effect  produced  on  the 
bladder.  If  the  pelvis  be  of  the  usual  size,  it  may  take  place  at 
any  time  during  the  third  and  fourth  months  of  pregnancy  'J a)  or 
if  the  pelvis  be  large,  or  the  ovum  not  much  distended  with  water, 
it  may  occur  in  the  fifth  month.  It  may  also  be  produced,  when 
the  womb  is  enlarged  to  a  certain  degree  by  disease.*  We  recog- 
nize retroversion  of  the  uterus  chiefly  by  its  effects  on  the  bladder, 
and  also  by  difficulty  in  voiding  the  faeces ;  for  although  the  patient 
may  be  distressed  sometimes  with  tenesmus,  she  usually  passes 
little  at  a  time.  When  the  retroversion  is  completed,  bearing-down 
pains  may  be  excited,  as  if  an  attempt  were  made  to  expel  or  force 
down  the  uterus  itself;  and  in  some  instances  equal  the  pains  of 
labour  itself.  These  are  much  connected  also  with  the  state  of  the 
bladder,  being  most  severe  when  it  is  distended,  and  generally  abat- 

faj  A  suppression  of  urine  from  retroversion  of  the  uterus,  may  arise  at  other 
periods,  as  well  as  during-  a  state  of  pregnancy,  and  generally  from  the  same 
cause,  viz.  over-distention  of  the  bladder.  Thus,  after  delivery,  the  uterus  some- 
times becomes  retroverted,  occasioning  an  entire  suppression  of  urine,  and  ex- 
cessive pain ;  and  the  same  thing,  not  uncommonly,  takes  place  when  the  uterus 
is  in  a  state  of  disease ;  and  sometimes  at  the  period  of  life  when  the  catamenia 
usually  cease.  At  this  period  the  uterus  is  apt  to  enlarge  and  grow  heavy,  with- 
out manifesting  any  other  indications  of  disease ;  and  in  this  state  more  than  one 
instance  has  occurred  of  its  becoming  retroverted. 

Dr.  Merriman  says,  that  the  cases  of  retroversion  of  the  uterus  after  deliver}', 
which  have  fallen  under  his  observation,  have  principally  occurred  on  the  second 
day  after  the  birth  of  the  child;  probably  because  the  degree,  of  contraction, 
which  the  womb  has  by  that  time  undergone,  has  reduced  it  to  a  size  the  most 
fit  to  suffer  such  a  displacement.  It  has  happened  after  easy  labours,  and  notwith- 
standing the  patients  have  passed  their  urine  once  or  twice.  The  second  day  after 
delivery  has  not,  however,  been  invariably  the  period  of  this  occurrence  ;  for  a 
case  occurred  to  Dr.  Merriman,  where  the  patient  was  attacked  with  a  suppres- 
sion of  urine  from  this  cause  on  the  ninth  day  after  delivery.  Vide  "  Merriman's 
Dissertation  on  Retroversion  of  the  Womb,"  p.  19,  20. 

*  Mr.  Pearson  relates  a  case,  where  the  uterus  was  retroverted,  in  consequence 
of  being  scirrhous.  Vide  Pearson  on  Cancer,  p.  113.  Dr.  Marcet  gives  an  in- 
stance where  the  uterus  was  retroverted,  without  pregnancy,  producing  consti- 
pation and  vomiting.  Vide  Cooper  on  Hernia,  pail  II.  p.  60.  Desault  observes, 
it  came  by  a  uterine  polypus. 


245 

ing  in  frequency  and  force,  when  the  urine  is  evacuated.  The 
acute  symptoms  produced  by  the  distention  of  the  bladder,  or  the 
inability  to  pass  the  urine  freely,  first  of  all  call  the  attention  of  the 
patient  to  the  disease ;  and  when  we  come  to  examine  her,  we  find 
a  tumour  betwixt  the  rectum  and  vagina.*  This  is  formed  by  the 
fundus  uteri,  which  is  thrown  backwards  and  downwards,  whilst 
the  os  uteri  is  directed  forward,  and  sometimes  so  much  upwards, 
as  not  to  be  felt  by  the  finger.  This  is  a  disease  which  we  would 
think  cannot  be  mistaken,  and  yet  it  is  sometimes  difficult  to  distin- 
guish it ;  for  in  extra-uterine  pregnancy,  it  has  happened,  that  the 
symptoms  have  been  nearly  the  same  with  those  of  retroversion  ;f 
and  tumour  of  the  ovarium  has  sometimes  produced  similar  effects. 
Perhaps  the  diagnosis  cannot,  in  every  case,  be  accurately  made, 
but  this  is  of  less  immediate  importance,  as  the  indications  in  such 
instances  must  be  the  same,  namely,  to  draw  off  the  urine,  and  pro- 
cure stools. 

Retroversion  may  take  place  slowly,  uiflier  two  different  circum- 
stances, and  from  two  causes,  which  I  will  notice  in  the  conclusion 
of  the  section.  In  the  one  case  it  takes  place  more  slowly,  and  it 
has  been  said  that  its  progress  could  be  ascertained  from  day  to 
day  ;J  in  the  other  it  occurs  pretty  quickly ;  and  occasionally  the 
woman  has  been  sensible  at  the  time,  of  a  tumbling  or  motion 


*  M.  Baudelocque  relates  a  case,  where  the  fundus  uteri  protruded  at  the  os 
externum,  the  patient  at  the  same  time  having  violent  inclination  to  expel  some- 
thing. He  was,  however,  able  speedily  to  reduce  the  womb  to  the  proper  state; 
Vide  l'Art,  8cc.  §  125.  In  Dr.  Bell's  case,  a  portion  of  the  rectum  was  protruded 
by  the  uterus.     Med.  Facts,  Vol.  VIII.  p.  52. 

f  Vide  Mr.  Gifford's  case  in  Phil.  Trans.  Vol.  XXXVI.  p.  435.  and  Mr.  White's 
very  instructive  case,  in  Med.  Comment.  Vol.  XX.  p.  254. 

}  M.  Baudelocque  gives  a  case  of  this  kind,  4  253.  In  Dr.  Bell's  case,  as  the 
woman  complained  for  five  weeks  of  dysuria  only,  it  is  likely,  that  for  that  period, 
the  retroversion  was  not  complete.  Med.  Facts,  Vol.  V11I.  p.  32.  Dr.  Hunter 
supposed  that  it  might  take  place  in  various  degrees;  it  might  be  complete,  or 
semi-complete,  or  even  the  os  uteri  might  remain  in  its  natural  situation.  He 
says,  that  Dr.  Combe  and  he  saw  a  case,  where  the  os  uteri  was  pushing  out  as  in 
a  procidentia  ;  but  this  perhaps,  will  not  be  admitted  to  have  been  retroversion. 
Med.  Obs.  and  Inq.  Vol.  V. p.  388.  In  the  same  volume,  p.  382,  Dr.  Garthshoie 
relates  an  instance  of  semi -retroversion . 


246 

within  the  pelvis.  Sometimes  the  urine  dribbles  away  involunta- 
rily, or  can  be  passed  in  small  quantity,  especially  during  the  com- 
mencement of  the  disease ;  but  often  within  a  few  hours,  it  be- 
comes almost  completely  obstructed,  with  pain  about  the  loins, 
tenderness  in  the  lower  belly  when  it  is  touched,  and  a  severe 
bearing-down  sensation.  The  great  danger  proceeds  from  the  dis- 
tention* of  the  bladder,  which  either  burstsf  or  inflames,};  and  an 
opening  takes  place,  in  consequence  of  gangrene ;  or  the  bladder 
adheres  to  the  abdominal  parietes,  its  coats  becoming  thickened 
and  diseased.^  If  the  urine  cannot  be  drawn  off,  of  which  I  have 
never  yet  met  with  an  instance,  and  do  not  believe  that  such  a  case 
can  occur ;  death  is  preceded  by  abdominal  pain,  vomiting,  hic- 
cup, and  sometimes  convulsions.  These  effects  are  chiefly  produced 
by  mistaking  the  nature  of  the  complaint.  Their  duration  is  varia- 
ble. ||  Inflammation  and  gangrene  of  the  vagina  and  external  parts 
have  also  been  produced.  If  the  disease  do  not  prove  rapidly  fa- 
tal, so  much  urine  escaping  as  to  prevent  a  speedy  termination,  it 
occasionally  happens,  that  the  hectic  fever  is  produced.  The  pulse 
becomes  frequent,  the  body  wastes,  and  purulent  urine  is  voided  ;1T 

*  In  the  case  described  by  Dr.  Hunter,  Med.  Obs.  and  Inq.  Vol.  IV.  p.  400, 
the  bladder  after  death  was  found  to  be  amazingly  distended,  but  not  ruptured. 

f  In  Mr.  Lynn's  case,  the  bladder  burst,  and  immediately  afterwards  the  wo- 
man miscarried,  but  the  uterus  after  death  was  found  to  be  still  displaced.  Med. 
Obs.  and  Inq.  Vol.  V.  p.  388.  Dr.  Squires  relates  an  instance  in  which  the  blad- 
der also  gave  way.     Med.  Review  for  1801. 

i  In  Mr.  Wilmer's  case,  the  belly  was  greatly  distended;  six  pints  of  urine 
were  drawn  off,  but  the  woman  soon  died.  On  inspecting  the  body,  the  bladder, 
from  the  disease  of  its  surface,  was  found  to  contain  a  quantity  of  coagulated 
blood,  and  the  inflammation  had  spread  to  the  colon.  In  this  case  the  umbilicus 
was  protruded  like  half  a  melon,  and  the  disease  was  at  one  time  taken  for  her- 
nia. The  uterus  was  found  to  be  so  firmly  wedged  in  the  pelvis  that  it  could 
not  be  raised  up  till  the  symphysis  pubis  was  sawed  away.  Wilmer's  Cases,  p. 
284. 

§  In  Dr.  Ross's  patient,  after  the  uterus  was  reduced,  abortion  took  place ; 
and  the  woman  dying,  the  bladder  was  found  to  be  thickened,  and  adhering  to 
the  navel.     Annals  of  Medicine,  Vol.  IV.  p.  284. 

!!  Dr.  Perfect's  patient  died  thus  on  the  sixth  day.  Cases  in  Midwifery,  Vol. 
I.  p.  394. 

T  This  is  illustrated  by  Dr.  Garthshore's  patient,  who,  notwithstanding  these 
symptoms,  ultimately  did  well.  After  the  reduction  of  the  womb  she  miscarried-, 


247 

or  the  person  may  become  cedematous,  and  the  disease  pass  for 
dropsy  ;*  occasionally  the  water  is  not  quite  obstructed,  but  it  is 
voided  with  difficulty  for  a  week  or  two,  and  then  the  symptoms 
become  more  acute,  and  forcing  pains  are  excited. 

Our  first  object  is  to  relieve  the  bladder,  by  introducing  a  cathe- 
ter,f  which  may  be  slightly  curved,  the  concavity  being  directed 
to  the  sacrum  ;  or  we  may  employ  an  elastic  catheter ;  but  in  ge- 
neral, the  common  instrument  succeeds.  If  it  do  not  pass  easily, 
we  may  derive  advantage  from  introducing  the  finger  into  the  va- 
gina, and  endeavouring  to  depress  the  os  uteri,  or  press  back  the 
vaginal  tumour.J  If  the  catheter  cannot  be  introduced,  we  have 
been  advised  to  tap  the  bladder  §  but  this,  fortunately,  is  never  re- 
quisite. 

We  must  not  be  deceived  with  regard  to  the  state  of  the  bladder, 
by  observing  that  the  woman  is  able  to  pass  a  small  quantity  of 
water,  for  it  may,  nevertheless,  be  much  distended.  We  must  ex- 
amine the  belly,  and  attend  to  the  sensation  produced  by  pressure 
on  the  hypogastric  region.  Even  although  the  catheter  have  been 
employed,  only  part  of  the  urine  may  have  been  drawn  off,  par- 
ticularly if  the  complete  evacuation  has  not  been  assisted  by  mo- 
derate pressure  over  the  bladder.  It  has  happened,  that  only  so 
much  has  been  taken  away  as  to  give  a  little  relief,  and  alter  the 


and  fetid  lumps  were  for  some  time  discharged  from  the  bladder.  Med.  Obs. 
and  Inq.  Vol.  V.  p.  382. 

*  In  Mr.  Croft's  case,  the  disease  was  of  a  month's  standing,  the  woman  was 
(edematous,  and  she  was  supposed  to  have  dropsy  :  but  by  introducing  the  ca- 
theter, seven  quarts  of  urine  were  drawn  off.  The  introduction  was  daily  re- 
peated for  some  time,  and  then  occasionally,  as  circumstances  required,  for  three 
weeks.  The  swelling  of  the  legs  went  off,  and  the  uterus  gradually  rose.  Med. 
Jour.  Vol.  XI.  p.  381. 

f  A  case  is  related  by  Mr.  Ford,  in  which  the  catheter  being  allowed  to  slip 
into  the  bladder,  produced  a  sinous  ulcer.     Med.  Facts,  Vol.  I.  p.  96. 

t  In  Mr.  Hooper's  case,  whenever  the  tumour  was  pressed  back,  the  woman 
called  out  that  she  could  now  make  water.     Med.  Obs.  and  Inq.  Vol.  V.  p.  104. 

§  This  was  done  by  Dr.  Cheston.  The  woman  remained  long  very  ill,  but  she 
carried  her  child  to  the  full  time,  and  recovered.  Med.  Gommun.  Vol.  II.  p.  96. 
In  one  instance,  by  using  a  long  trocar,  the  uterus  was  wounded,  and  the  woman 
died. 


248 

position  of  the  uterus  so  much  as  to  lessen  the  pressure  on  the  ori- 
fice of  the  bladder.  In  this  case,  on  getting  up,  a  great  quantity 
of  urine  has  flowed  spontaneously,  and  the  womb  immediately  re- 
turned to  its  proper  state. 

The  urine  being  evacuated,  and  the  most  immediate  source  of 
alarm  being  thus  removed,  we  must,  in  the  next  place,  procure  a 
stool,  by  means  of  a  clyster;  detract  blood,  if  there  be  fever  or 
restlessness ;  and  give  an  anodyne  injection,  if  there  be  strong  bear- 
ing-down efforts.  This  is,  in  general,  all  that  is  requisite ;  and  I 
wish  particularly  to  inculcate  the  necessity  of  directing  the  chief 
attention  to  the  bladder,  which  ought  to  be  emptied  at  least  morn- 
ing and  evening,  or  a  gum  catheter  may  be  left  in  the  bladder.  By 
this  plan,  we  generally  find,  that  the  uterus  resumes  it  proper  situa- 
tion in  the  course  of  a  short  time,  perhaps  in  forty-eight  hours  ;* 
and  the  retroversion  is  seldom  continued  for  more  than  a  week, 
unless  the  displacement  have  been  very  complete.  The  precise 
time,  however,  required  for  the  ascent  of  the  womb  will  be  deter- 
mined ceteris  paribus,  by  the  degree  to  which  it  has  been  retro- 
verted,  and  the  attention  which  is  paid  to  the  bladder.  If  the  fun- 
dus be  very  low,  the  ascent  may  be  tedious  ;  but  I  consider  my- 
self as  warranted  from  experience  to  say,  that  in  every  moderate 
degree  of  retroversion,  in  every  recent  case,  it  is  sufficient  to  empty 
the  bladder  regularly  without  making  any  attempt  to  push  up  the 
womb.  But  if  the  uterine  tumour  be  very  low,  and  near  the  peri- 
neum, it  may  be  necessary,  and  certainly  it  is  allowable,  to  endeavour 
to  replace  the  womb.  This  is  also  proper  if  there  be  much  irritation 
excited  by  the  state  of  the  womb,  and  which  does  not  give  way  to  the 
use  of  the  catheter,  and  of  anodyne  clysters.  I  fear,  however,  that 
these  efforts  are  too  keenly  made,  and  that  often  more  harm  than 
good  is  done  by  them.  It  may  be  said,  that  although  the  imme- 
diate danger  be  done  away  by  the  regular  use  of  the  catheter,  yet 
the  womb  may  remain  for  ever  in  its  malposition,  and  give  rise  to 

*  Dr.  Hunter  mentions  a  case,  in  which  the  uterus  recovered  itself  immediate- 
ly after  the  bladder  was  emptied.  Med.  Obs.  Vol.  IV.  p.  408.  And  in  Mr.  Croft's 
second  case,  the  water  having  been  drawn  off  for  six  days,  the  uterus  sildde.nl} 
rose.    I.ond.  Med.  Jour.  Vol.  XI.  p.  384k 


249 

great  difficulty  in  labour,  or  to  the  same  event  as  in  extra-uterine 
pregnancy.  I  can  only  reply,  that  in  almost  every  instance  where 
the  bladder  has  been  regularly  emptied,  the  case  has  done  well ; 
and  1  do  believe,  that  in  those  where  the  uterus  did  not  rise  spon- 
taneously, very  little  good  could  have  been  done  by  mechanical  ef- 
forts. 

The  attempt  to  replace  the  uterus  is  to  be  made  by  introducing 
the  whole  hand  into  the  vagina.  The  uterine  tumour  is  then  to 
be  pressed  up  slowly,  firmly,  and  steadily;  and  this  may  some- 
times be  assisted  by  elevating  the  breech  of  the  woman.  Forcible 
and  violent  attempts  are,  however,  to  be  strongly  reprobated ; 
they  give  great  pain,  and  may  even  excite  abortion,  inflammation, 
or  convulsions.  They  can  only  be  justified  on  the  principle  of 
preventing  a  great  danger.  Now  we  know  that  the  chief  risk  pro- 
ceeds from  the  distention  of  the  bladder ;  if,  therefore,  it  can  be 
emptied,  the  danger  is  usually  at  an  end.  When  the  retroversion 
ceases,  the  uterus  usually  resumes  completely  its  proper  situation ; 
but  it  sometimes  happens,  especially  if  the  vagina  have  been  much 
relaxed,  that  when  the  retroversion  is  removed,  the  uterus  is  found 
very  low,  forming  a  prolapsus,  which  continues  for  some  time.  It 
requires,  chiefly,  attention  to  the  urine  and  stools;  for  it  may  oc- 
cupy the  pelvis  fully,  and  pretty  firmly ;  and  almost  the  whole 
fetus  can  be  felt  by  the  finger  through  the  uterus. 

When  the  uterus  ascends,  occasionally  a  little  blood  is  dis- 
charged j*  but  abortion  does  not  take  place  unless  much  injury 
has  been  sustained.  Thus  the  woman  has  miscarried  quickly  after 
the  bladder  had  burst,  as  in  Mr.  Lynn's  patient;  or  when  inflam- 
mation had  taken  place,  as  in  the  cases  related  by  Drs.  Bell  and 
Ross.  When  this  happens,  the  uterus  rises  indeed,  but  the  patient 
is  cut  off  by  peritoneal  inflammation,-)-  followed  by  vomiting  of 
dark  coloured  stuff.  Abortion  will  generally  take  place,  if  the 
liquor  amnii  have  been  discharged. 

*  M.  Roger's  case,  in  Act.  Havn.  Tom.  II.  art.  17. 

f  Both  Dr.  Ross's  patient,  and  Dr.  Clieston's  patient,  the  latter  of  whom  re- 
covered, complained  of  uneasiness  in  the  throat,  which  Dr.  C.  considers  as  :i 
mark  of  slow  peritoneal  inflammation. 

58 


250 

That  the  uterus  does  generally  rise  spontaneously,  if  the  urine 
be  regularly  evacuated,  is  a  fact  of  which  I  am  fully  convinced 
from  my  own  experience,  as  well  as  from  the  observations  of 
others.  But  it  is  nevertheless  possible  for  it  to  continue  in  a  cer- 
tain degree  of  malposition  even  to  the  end  of  gestation.*  In  this 
case,  the  uterus  cannot,  indeed,  at  last  be  said  exactly  to  be  retro- 
verted;  for  it  has  enlarged  so  much  that  it  occupies  nearly  as  much 
of  the  abdomen  as  usual;  but  it  has  enlarged  in  a  peculiar  way, 
the  os  uteri  being  still  directed  to  the  symphysis  pubis,  or  even 
perhaps  raised  above  it.  In  such  a  case,  which  is  exceedingly 
rare,  the  labour  will  be  very  tedious  and  severe.  The  os  uteri 
must  be  very  long  of  being  felt,  and  be  first  perceived  at  the 
pubis.(6J     We  are  indebted  to  Dr.  Merriman  for  an  explanation 

*  This  circumstance  has  been  mentioned  by  different  writers,  and  a  distinct 
case  is  related  by  Dr.  Merriman,  in  the  Med.  and  Phys.  Jour.  Vol.  XVI.  p. 
388.  Mrs.  F.  being  about  five  months  pregnant,  was  suddenly  terrified  and  felt 
as  if  her  inside  were  turned  upside  down.  The  symptoms,  however,  were  not 
very  acute,  for  she  voided  the  urine  in  the  last  month  of  gestation,  though  with 
pain  and  some  difficulty.  On  the  16th  of  June,  she  had  some  pains,  and  a  dis- 
charge of  serous  fluid ;  no  os  uteri  could  be  felt,  but  a  large  semi-globular  tu- 
mour at  the  back  part  of  the  vagina,  bearing  down  toward  the  perineum.  The 
pains  brought  on  fever,  and  at  last  delirium  and  convulsions.  She  was  bled,  and 
had  a  clyster,  after  which  she  got  some  sleep,  and  the  pains  continued  moderate, 
though  regular,  for  two  or  three  days,  and  she  passed  both  urine  and  stools.  On 
the  20th,  nothing  like  os  uteri  could  be  felt;  but  on  the  21st,  there  was  per- 
ceived a  thick  flattened  fleshy  6iibstance  descending  into  the  vagina,  and  very 
soon  the  uterus  was  restored  to  its  natural  situation.  The  substance  was  found 
to  be  the  scalp  of  the  child,  containing  loose  bones.  The  child  and  placenta 
were  delivered,  and  the  mother  recovered. 

fbj  The  first  case  of  this  kind  that  has  been  accurately  stated  as  such,  is  to 
be  met  with  in  a  small,  but  judicious  work,  by  Dr.  H.  S.  Jackson,  entitled, 
"  Cautions  to  Women  respecting  the  State  of  Pregnancy.  London,  1798,"  and 
was  attended  by  several  of  the  most  respectable  practitioners  of  London  ;  the 
next  case  which  has  been  made  public,  was  that,  which  fell  under  the  immediate 
notice  of  Dr.  Merriman,  and  by  him  minutely  detaded  in  the  London  Medical 
and  Physical  Journal,  for  1806;  and  afterwards  published  in  a  distinct  and  sepa- 
rate work,  entitled,  "  A  Dissertation  on  Retroversion  of  the  Womb,  including 
some  Observations  on  Extra-uterine  Gestation.    London,  1810." 

It  will  be  found  by  consulting  Dr.  Merriman's  paper  and  work  above  alluded 
to,  that  he  considers,  and  with  some  appearance  of  probability,  that  certain  of 


251 

«f  this  fact,  and  likewise  for  the  observation  that  it  is  possible  for 
the  termination  to  be  similar  to  that  of  extra-uterine  pregnancy, 
namely,  by  suppuration.  A  case  of  this  kind,  well  marked  in  all 
respects,  except  suppression  of  urine,  is  related  by  Dr.  Barnum,* 
as  an  instance  of  extra-uterine  gestation.  In  the  fifth  month,  after 
some  imprudence,  the  patient  had  pain  accompanied  with  a  dis- 

those  cases  of  difficult  labour,  which  by  Deventerhave  been  referred  to  his  sup. 
posed  obliquity  of  the  uterus,  and  others,  which  have  by  different  authors,  been 
considered  as  cases  of  extra-uterine  conception,  were,  in  fact,  cases  of  retrover- 
sions of  the  uterus  continuing,  in  a  certain  degree,  until  the  full  period  of  utero- 
gestation,  and  then  impeding  delivery.  He  likewise  observes,  that  it  is  not  un- 
likely, that  some  of  those  cases  which  are  found  in  Smellie's  and  other  collections, 
where  the  os  uteri  is  described  as  grown  together  and  impervious,  were  actually 
retroversions  of  the  uterus.  In  these  cases  incisions  have  been  frequently  made 
within  the  vagina,  into  the  uterus.  [Vide  Sabatier,  Medicine  Operatoire,  Vol.  I. 
p.  310.] 

There  is  also  another  class  of  cases,  of  which  many  are  recorded  by  writers  on 
Midwifery,  which  may  probably  owe  their  origin  and  cause  to  a  retroverted 
state  of  the  uterus.  We  here  allude  to  those  cases  of  extra-uterine  foetuses  dis- 
charged per  anum,  or  through  an  ulcerated  opening  in  the  vagina,  after  having 
remained  for  many  years  in  the  abdomen  of  the  mother.  [Vide  Mainwaring,  in  2d 
Vol.  of  Transactions  of  the  Society  for  the  Improvement  of  Med.  and  Chirurg. 
Knowledge,  and  Coleman,  in  2d  Vol.  of  Med.  and  Phys.  Journal,  and  Gifford,  in 
Eclectic  Repertory,  Vol.  I.  p.  346,  and  seq.] 

"When  foetuses  have  been  found  in  the  cavity  of  the  abdomen  entirely  disen- 
gaged from  the  uterus,  it  is  probable  that  a  rupture  of  this  viscus,  or  an  ulcerated 
opening  through  its  parietes,  in  consequence  of  its  deranged  situation,  had  per- 
mitted the  escape  of  the  foetus  after  it  had  ceased  to  live,  and  not  that  the  con- 
ception had  advanced  to  maturity,  in  a  part  apparently  so  illy  adapted  to  such  a 
purpose. 

By  this  explanation,  we  may  solve  what  has  hitherto  been  to  many  a  difficulty 
in  the  history  of  these  cases.  It  has,  for  instance,  been  observed  in  every  case 
of  foetus,  carried,  as  it  was  supposed,  in  the  abdomen  beyond  the  period  of  nine 
months,  that  near  the  usual  time  of  parturition,  the  pains  of  labour  have  regu- 
larly come  on,  and  strong  efforts  appear  to  have  been  made  by  the  uterus,  as  if 
for  the  expulsion  of  the  child. 

Now,  as  it  has  been  well  observed,  it  is  difficult  to  assign  any  reasons  for  these 
contractions  of  the  uterus,  if  the  foetus  has  no  connection  with  that  organ  ;  but 
if  the  foetus  is  contained  in  the  partially  retroverted  uterus,  or  in  any  of  the  ap- 
pendnges  of  the  uterus,  the  occurrence  of  these  contractions  might  naturally  be 
expected.    Vide  Dr.  Merriman's  paper  and  work  above  referred  to. 

*  Vide  New  York  Med.  Rep.  V.  40. 


252 

charge  of  water  and  some  blood,  a  mark  that  the  ovum  was  in  the 
uterus.  She  got  relief  at  this  time ;  but  next  month,  (Nov.)  she 
had  a  return  of  pain,  and  the  os  uteri  was  felt  directed  to  the  pubis, 
and  the  fundus  to  the  sacrum.  All  attempts  to  reduce  it  failed, 
suppuration  took  place,  and  foetal  bones  were  discharged  by  the 
anus.     She  died  in  March. 

In  order  to  prevent  retroversion,  we  must  understand  its  cause, 
which  most  frequently,  if  not  always,  consists  in  distention  of  the 
bladder.  But  this  may  take  place  under  two  circumstances.  First, 
the  uterus  may  descend  lower  than  usual.  Its  mouth  and  cervix 
fall  dowi.ward  and  forward,  the  fundus  lies  back  in  the  hollow  of 
the  sacrum,  and  the  body  is  placed  obliquely.  It  is  indeed  a  sim- 
ple case  of  prolapsus  ;  but  thereby  pressure  is  made  on  the  urinary 
passage,  retention  of  urine  is  necessarily  produced,  the  bladder  is 
distended,  and  thus  the  os  uteri  is  raised  and  drawn  more  forward, 
and  retroversion  gradually  accomplished.  In  this  case  the  primary 
cause  is  the  pressure  of  the  uterus  on  the  urethra  or  bladder,  and 
the  bladder  re-acts  on  the  womb.  Second,  if  the  female  retain  the 
urine  too  long,  the  bladder  is  distended,  and  from  its  connection 
with  the  uterus,  must  affect  its  position,  whatever  its  former  state 
may  have  been.  The  os  uteri  is  elevated,  and  the  fundus  falls  in 
the  same  proportion  backward.  Now  in  the  unimpregnated  state, 
the  uterus  is  not  sufficiently  large  to  remain  retroverted ;  and  after 
the  fourth  month  of  pregnancy,  the  uterus  is  too  heavy  to  be  much 
raised  by  the  bladder,  and  too  large  to  fall  into  the  pelvis.  If,  how- 
ever, the  pelvis  be  very  wide,  and  the  uterus  have  consequently 
been  longer  than  usual  of  rising,  it  may  be  retroverted  at  a  later 
period.  It  would  appear,  that  agitation,  or  violent  exertion,*  may 
cause  this  state  to  take  place  more  readily  than  would  otherwise 
happen  ;  but  whether  concussion,  or  other  circumstances,  can  pro- 

*  In  Mr.  Bird's  case,  the  accident  succeeded  to  stooping,  in  washing  clothes. 
Med.  Obs.  and  Inq.  Vol.  V.  p.  100.  In  Mr.  Hooper's  case,  the  woman  was  fright- 
ened by  an  ox,  and  in  attempting  to  escape,  fell  down,  after  which  the  symptoms 
appeared.  Mr.  Evan's  patient  ascribed  it  to  lifting  a  burden.  Med.  Comment. 
Vol.  VI.  p.  215  :  and  Mr.  Swan's  patient  to  a  fall,  p.  217.  Dr.  Merriman's  patient 
first  complained  after  being  suddenly  terrified ;  and  Mr.  Wilmer's  patient  had  the 
uterus  retroverted,  after  being  fatigued  with  weeding. 


253 

duce  retroversion,  without  some  previous  distention  of  the  bladder, 
is  not  positively  proved,  though  some  facts  favour  the  supposition. 

Retroversion  is  sometimes,  but  not  necessarily,  followed  by 
abortion.  It  has  no  influence  in  altering  the  presentation  of  the 
child. 

The  same  woman  has  been  known  to  have  the  uterus  retroverted 
in  two  successive  pregnancies.*  Retroversion  may  also  take  place 
after  delivery. 

§  34.  ANTIVERSION. 

The  uterus  is  also  said  to  be  sometimes  antiverted,  that  is,  the 
fundus  is  thrown  forward,  so  as  to  compress  the  neck  of  the  blad- 
der, and  its  mouth  is  turned  to  the  sacrum.f  Of  this  accident  I 
have  never  seen  an  instance,  and,  from  the  nature  of  the  case  it 
must  be  very  rare.  The  urine  should  be  evacuated,  and  the  fundus 
raised  up.  The  symptoms  are  described  to  be,  weight  in  the  lower 
part  of  the  belly,  a  desire  to  make  water,  but  difficulty  in  doing  so, 
the  existence  of  a  tumour  near  the  pubis,  and  an  impediment  to  the 
passage  of  the  faeces. 

§  35.  RUPTURE  OF  UTERUS. 

Rupture  of  the  gravid  uterus  may  take  place  at  any  period  of 
gestation.  The  moment  of  the  accident  is  generally  marked  by  se- 
vere pain,  occasionally  by  vomiting,  and  frequently  by  a  tendency 
to  syncope,  which,  in  some  instances,  continues  for  a  length  of 
time  to  be  the  most  prominent  symptom. J  The  pain  sometimes 
resembles  labour,  but  more  frequently  colic,  and  its  duration  is  va- 

*  Vide  case  by  Dr.  Senter,  in  Trans,  of  Phys.  at  Philadelphia,  p.  130.  Both 
times  it  was  reduced  by  the  hand. 

f  Vide  Chambon,  Malad.  de  la  Grossesse,  p.  16.  M.  Baudelocque  relates  a 
case  from  the  practice  of  Choppart,  where  it  was  produced  in  the  second  month 
of  pregnancy,  by  the  action  of  an  emetic.  L'Art,  &c.  §  255.  Levret  notices  a 
case  where  the  disease  was  mistaken  for  calculus,  and  the  operation  of  lithotomy 
actually  performed.    Journ.  de  Med.  T.  IV.  p.  269. 

i  Vide  Dr.  Underwood's  case,  in  Lond.  Med.  Journ.  Vol.  VJl.  p.  321. 


254 

liable.  In  some  cases,  hemorrhage  takes  place  from  the  vagina, 
but  the  greatest  quantity  of  the  blood*  flows  into  the  abdomen.  At 
the  time  of  the  accident,  and  for  a  little  thereafter,  the  child  is  felt 
to  struggle  violently.  Then  the  motion  ceases,  the  woman  feels  a 
weight  in  the  belly,  and,  if  the  pregnancy  be  far  advanced,  the 
members  of  the  child  can  be  traced  through  the  abdominal  pari- 
etes.f  The  tumour  of  the  belly  generally;};  lessens,  and  milk  is  se- 
creted, indicating  the  death  of  the  child. 

If  hemorrhage,  or  peritoneal  inflammation,  do  not  quickly  carry 
off  the  patient,  we  find,  that  at  the  end  of  some  time,  occasionally 
of  the  ninth  month  of  gestation,  pains  like  those  of  labour  come 
on,  which  either  gradually  go  off,  and  the  child  is  retained  for 
many  years,^  being  inclosed  in  a  kind  of  cyst;  or  inflammation 
and  abscess  take  place,  and  the  child  is  discharged  piece-meal.  || 

In  some  instances,  it  would  appear,  that  the  ovum  may  be  ex- 
pelled entire  into  the  abdomen ;  and  in  that  case,  it  is  possible  for 

*  Sometimes  the  hemorrhage  proves  fatal.  A  singular  case  is  to  be  met  with 
in  Medical  Facts,  Vol.  III.  p.  171,  by  Canestrini,  where  the  woman  had  a  double 
uterus.  One  of  the  uteri,  after  some  pains,  burst  in  the  fourth  month.  The  ovum 
was  found  entire  in  the  abdomen,  and  much  blood  was  effused. 

-j-  A  twin  case  is  related  by  Dr.  J.  Hamilton,  where  the  uterus  was  so  thin,  that 
even  the  sutures  of  the  head  could  be  felt  through  the  abdominal  parietes.  Vio- 
lent pains  were  produced  by  the  motion  of  the  child,  the  uterus  felt  very  light* 
and  the  woman  had  been  exposed  to  a  degree  of  violence.  This  case  had  a  very 
considerable  resemblance,  in  some  respects,  to  a  ruptured  uterus,  but  she  was  de- 
livered safely  of  two  children.     Cases,  p.  124. 

i  Sometimes  the  tumour  rather  increases.  In  Dr.  PercivaPs  case,  the  belly  be- 
came much  larger  after  the  accident,  and  continued  so  for  about  a  year.  Then  it 
subsided  all  at  once,  when  the  woman  was  in  a  recumbent  posture.  Med.  Com- 
ment. Vol.  II.  p.  77. 

§  In  Dr.  Percival's  case  the  foetus  was  retained  for  22  years,  and  then  dis- 
charged by  the  rectum. 

||  Dr.  Drake's  case,  where  the  uterus  seemed  to  burst  in  the  fourth  month, 
terminated  by  suppuration  at  the  navel.  Excrement  was  for  some  time  dis- 
charged at  the  opening.  Phil.  Trans.  Vol.  XLV.  p.  121. — A  washerwoman  at 
Brest  had  the  uterus  ruptured  by  a  fall  in  the  seventh  month,  and  ultimately  ex- 
pelled the  foetus  at  the  navel.  Mem.  of  Acad,  of  Sciences  for  1709. — Guillerm, 
in  the  same  work,  for  1706,  mentions  a  woman  who  had  the  womb  ruptured  by 
a  fall  in  the  sixth  month.  She  immediately  fainted,  and  a  discharge  took  place 
from  the  vagina.  The  child  was  expelled  by  the  anus. — See  also  the  cases  by 
Dr.  Percival,  Mr.  Wilson,  &c. 


Z5S 

the  child  to  live  for  some  time,  and  even  to  grow,  although  out  of 
the  uterus.  When  this  happens,  its  motions  are  felt  more  freely 
and  acutely  than  formerly.  As  the  os  uteri  opens  a  little  after  the 
expulsion,  and  a  sanguineous  discharge  takes  place,  the  woman 
has  sometimes  been  supposed  to  miscarry.  If  she  survive,  the 
womb  slowly  decreases  in  size,  and  returns  to  the  unimpregnated 
state,*  which  will  assist  materially  in  the  diagnosis,  between  this 
and  extra-uterine  pregnancy  existing  from  the  first.  The  menses 
return,  and  though  the  belly  does  not  subside  completely,  yet  the 
person  continues  tolerably  well,  unless  inflammation  come  on.  She 
may  even  bear  children  before  the  extra-uterine  foetus  be  got  rid 
of.f     If  the  case  is  to  prove  fatal,  the  pulse  becomes  quick  and 

*  In  the  Journ.  de  Med.  for  1780,  there  is  a  case  of  a  woman,  who  had  the  ute- 
rus ruptured  in  the  fourth  month  of  pregnancy.  The  accident  was  followed  by 
uterine  hemorrhage,  which  continued  for  some  time.  The  menses  returned, 
but  the  belly  did  not  subside.  In  the  ninth  month  she  died.  The  uterus  was 
found  of  the  natural  size,  but  the  rent  was  still  perceptible. 

The  uterus  for  some  time  does  not  return  to  its  unimpregnated  state,  as  is  evi- 
dent from  the  following  case,  which  1  lately  saw.  Anne  Neilson,  aged  24  years, 
fell  on  the  ground  about  a  month  before  this  note  was  written,  being  then  in  the 
ninth  month  of  her  first  pregnancy.  She  felt  at  the  time  as  if  something  had 
burst  near  the  navel,  and  perceived  more  fluttering  of  the  child  than  usual.  This 
continued  in  a  certain  degree  for  two  days,  after  which  she  felt  no  more  motion. 
In  the  course  of  two  or  three  days  after  the  accident,  she  was  seized  with  irregu- 
lar pains,  chiefly  about  the  belly,  and  these  are  rather  increasing  than  diminish- 
ing in  severity.  The  belly  has  subsided  considerably  in  size,  is  hard,  particu- 
larly above  the  navel,  toward  the  stomach.  The  umbilicus  itself  is  soft  and  pro- 
minent. The  bowels  are  regular,  urine  proper,  tongue  clean,  heat  natural,  pulse 
84,  has  occasional  shivering  On  examining,  per  vaginam,  the  lower  part  of  the 
uterus  is  felt  soft  and  tubulated,  very  unlike  either  the  gravid  or  unimpregnated 
womb.  It  hangs  into  the  vagina,  like  a  fleshy  inverted  cone.  By  some  degree 
of  attention  the  os  uteri  is  discovered  at  the  lower  part,  or  rather  a  little  back- 
ward. It  has  no  distinct  projecting  lips  as  in  the  unimpregnated  state,  but  by 
pressure  with  the  finger,  the  aperture  is  felt  with  thin  margins,  and  the  point  ot 
the  finger  may  be  introduced  a  very  little  way  within  it.  The  head  of  the  child 
is  discovered  between  the  uterus  and  pubis.  No  distinct  member  can  be  felt 
through  the  abdominal  panetes. 

Dr.  Jeffray  possesses  a  preparation  of  a  foetus  contained  in  a  kind  of  cyst  taken 
from  a  woman  who  had  carried  the  child  above  twenty  years  :  the  rupture  was 
occasioned  by  a  fall. 

f  Vide  Journ.  de  Med.  Tom.  V.  p.  42?. 


256 

small,  the  belly  painful,  the  strength  sinks,  and  sometimes  conti- 
nued vomiting  ushers  in  dissolution.* 

Rupture  of  the  uterus  may  be  the  consequence  of  mental  agita- 
tion^ but  in  most  cases  it  is  owing  to  external  violence.J 

Three  modes  of  treatment  present  themselves,  when  the  uterus 
is  ruptured  during  gestation,  and  previous  to  labour.  To  leave  the 
case,  to  nature  ;  to  deliver  per  vias  naturales  ;  and  to  perform  the 
cesarean  operation.  To  dilate  the  os  uteri  forcibly,  and  thus  ex- 
Tract  the  child,  is  a  proposal  so  rash  and  hazardous,  that  I  know 

*  In  the  Journal  de  Med.  for  1780,  a  case  is  detailed  of  a  woman,  who,  in  the 
month  of  January,  being  then  seven  months  pregnant,  was  squeezed  betwixt  the 
wall  and  a  carriage,  and  had  the  uterus  ruptured.  She  instantly  felt  violent  pain 
in  the  belly,  and  a  discharge  took  place  from  the  vagina,  which  continued  in  va- 
riable quantity  for  six  weeks.  The  strength  gradually  sunk,  and  in  June  she 
began  to  vomit,  and  continued  to  do  so  for  several  days,  when  she  died.  The 
abdomen  was  found  inflamed,  and  contained  the  remains  of  a  putrid  child.  The 
rent  was  visible  in  the  womb. 

-J-  Dr.  Percival's  patient  attributed  her  accident  to  a  fright ;  Dr.  Underwood's 
referred  hers  to  mental  agitation. 

i  In  Mr.  Wilson's  patient,  the  accident  was  produced  by  being  kicked.  She 
complained  of  pains  all  night  after  the  injury,  and  next  day  had  a  sanguineous  dis- 
charge from  the  vagina,  and  soon  afterwards  was  attacked  with  violent  griping 
pain.  The  foetus  was  ultimately  discharged  by  an  abscess,  bursting  exte  lly. 
Annals  of  Med.  Vol.  II.  p.  317,  and  Vol.  VI.  p.  401.— Dr.  Garthshore's  pat:  as- 
cribed it  to  violent  exercise.    Med.  Journal,  Vol.  VIII.  p.  334 Mr.  Goodi        pa- 

tientto  exertion.  Annals  of  Med.  Vol.  VII.  p.  412. — In  the  5th  and  6tl  ume 
of  the  Journal  de  Med.  are  two  cases,  the  first  produced  by  a  fall  from  a  tree,  the 
second  by  a  bruise  from  a  wagon.     Other  instances,  if  necessary,  might  be  added. 

The  uterus  may  be  ruptured  by  a  variety  of  causes — 

1.  By  external  violence,  as  by  blows,  falls,  pressure,  &c. 

2.  By  rude  attempts  to  turn  the  child,  and  especially,  after  the  waters  are  dis- 
charged.    This  has  often  happened. 

3.  By  convulsions. 

4.  By  the  inordinate  action  of  the  uterus,  constituting  what  is  termed  sponta- 
neous rupture.  This  last  is,  by  much,  the  most  common  cause.  But  when  rup- 
ture is  thus  produced,  we  may  suspect  that  an  improper  treatment  has  been  pur- 
sued. We  can,  undoubtedly,  by  copious  bleeding,  and  the  subsequent  adminis- 
tration of  opium,  so  far  overcome  the  resistance,  and  mitigate  the  violence  of  the 
pains,  as  to  prevent  its  occurrence.  The  same  remedies  will,  moreover,  obviate, 
in  most  instances,  rupture  from  convulsions;  and  should  never  be  neglected  as 
precautionary  means,  where  there  are  any  apprehensions  of  the  accident  from 
turning  the  child.    C 


267 

none  in  the  present  day  who  would  adopt  it.  I  question  if  the  wo- 
man could  live  till  the  delivery  were  accomplished.  The  cesar- 
ean operation  is  safer,  and  in  every  respect  preferable;  but  we  can- 
not yet,  from  experience,  determine  its  advantages,  and  certainly 
it  ought  not  to  be  performed,  unless  we  can  thereby  save  the  child, 
or  the  patient  have  reached  a  very  advanced  period  of  pregnancy. 
The  third  proposal,  therefore,  to  leave  the  case  to  nature,  like  an, 
extra-uterine  pregnancy,  is  most  likely  to  be  successful,  more  espe- 
cially when  the  rupture  happens  in  the  early  months  of  gestation. 
We  find,  from  the  result  of  cases,  that  the  patient  has  the  best 
chance  of  recovery,  if  we  are  satisfied  with  obviating  symptoms^ 
and  removing  inflammation  in  the  first  instance  ;  and  supporting  the 
strength  of  the  patient  through  the  progress  of  the  disease,  should 
it  not  prove  rapidly  fatal ;  enjoining  rest,  giving  mild  diet,  and  fa- 
vouring the  expulsion  of  the  bones,  by  poultices  and  fomentations, 
and,  if  necessary,  by  enlarging  the  abscess,  if  it  point  externally* 

*  This  negative  sort  of  practice  has,  undoubtedly,  met  with  many  very  respecta= 
ble  advocates.  There  are,  at  the  present  day,  several  eminent  practitioners,  be- 
sides Mr.  Burns,  who  strenuously  recommend  it.  Notwithstanding,  however,  the 
weight  of  authority  in  its  favour,  I  cannot  believe  it  to  be  right.  The  powers  of 
nature  seem  to  me  to  be  totally  incompetent  in  such  cases.  By  prompt  delivery 
only  we  can  hope  to  do  good.  This,  then,  we  should  always  attempt.  In  some 
cases  the  forceps  may  be  used,  but  they  are  few,  as  the  rupture  commonly  takes 
place  before  labour  is  sufficiently  advanced  to  admit  of  their  application.  We, 
therefore,  turn  the  child,  and  bring  it  away  by  the  feet.  Delivery  in  this  manner 
has  been  more  than  once  effected,  and  the  woman  preserved,  even  where  the 
child  had  escaped  through  the  rupture  of  the  uterus  into  the  abdominal  cavity.  I 
allude  now  more  particularly,  to  the  case  recorded  by  Dr.  Douglass,  and  to  one 
which  occurred  to  Dr.  J.  Hamilton.  To  these,  I  may  also  add,  as  showing,  at  least, 
the  practicability  of  delivery  under  such  circumstances,  a  case,  related  by  my 
friend  Dr.  James,  in  the  Medical  Repository  of  New  York. 

Were  the  rupture  to  happen  in  the  earliest  stage  of  labour,  I  should  neverthe- 
less not  be  deterred  from  adopting  this  practice.  I  would  forcibly,  but  not  vio- 
lently, dilate  the  uterus.  It  does  not  strike  me  that  the  attempt  would  be  "  rash 
and  hazardous."  We  often  in  other  emergencies  do  it  with  advantage,  as  in  la- 
bour attended  with  hemorrhage  or  convulsions.  Why  may  it  not  also  be  done  in. 
lacerated  uterus  ? 

But  if,  by  deformity  of  the  pelvis,  or  contraction  of  the  uterus,  (the  child  being 
in  the  cavity  of  the  abdomen)  or  indeed  from  any  other  circumstances,  there  ex- 
ists insuperable  impediments  to  deliver)  per  vias  natural?*,  I  would,  without  h.es> 

34 


258 

The  uterus,  sometimes,  in  the  early  months  of  gestation,  is  open- 
ed by  a  kind  of  ulcer,  and,  occasionally,  by  a  species  of  slough ; 
either  of  which  states  proceeds  from  previous  disease  in  a  part  of  the 
womb.  There  may  be  pain  attending  this  process ;  but  in  such 
instances  as  I  have  known,  there  has  been  none.  The  patient, 
without  any  evident  cause,  has  been  seized  with  great  sickness, 
and  fits  of  fainting,  which,  in  a  few  hours  have  proved  fatal.  On 
examination,  there  will  be  found  much  blood  effused  in  the  pelvis 
or  cavity  of  the  abdomen,  and  perhaps  a  foetus  amongst  the  clots. 


§  36.  ABORTION  AND  TREATMENT  OF  PREGNANT  WOMEN. 

The  usual  period  of  utero-gestation  is  nine  months,  but  the  foe- 
tus may  be  expelled  much  earlier.  If  the  expulsion  take  place 
within  three  months  of  the  natural  term,  the  woman  is  said  to  have 
a  premature  labour  ;  if  before  that  time,  she  is  said  to  miscarry,  or 
have  an  abortion.  The  process  of  abortion  consists  of  two  parts, 
detachment  and  expulsion ;  but  these  do  not  always  bear  a  uni- 
form relation  to  each  other  in  their  degree.  The  first  is  productive 
of  hemorrhage,  the  second  of  pain ;  for  the  one  is  attended  with 
rupture  of  vessels,  the  other  with  contraction  of  the  muscular  fibres. 
The  first  may  exist  without  being  followed  by  the  second,  but  the 
second  always  increases,  and  ultimately  completes  the  first.    The 

tation,  resort  to  the  cesarean  section.  In  deliberating  on  the  expediency  of  adopt- 
ing this  dreadful  alternative,  we  should  constantly  bear  in  recollection  that  we 
are  not  without  examples  of  the  success  of  the  operation. 

Two  cases  with  favourable  results  are  related,  one  by  Dr.  Barlow,  and  the  other 
by  Dr.  J.  Hamilton.  In  the  latter  case,  the  bones  of  the  pelvis  were  so  mashed  by 
the  wheel  of  a  cart  as  altogether  to  prevent  delivery  by  the  natural  passages.  On 
opening  the  abdomen,  the  child  was  found  in  the  cavity,  and  the  uterus  consider- 
ably lacerated.  But  notwithstanding  the  extent  and  severity  of  the  injury,  the 
woman  entirely  recovered. 

Let  it  not,  however,  be  understood  that  I  am  at  all  sanguine  as  regards  the  two 
remedies  which  I  have  proposed.  I  am,  on  the  contrary,  persuaded  that  in  most 
instances,  they  will  wholly  fail.  But  what  else  can  be  done  in  these  tremendous 
cases?  To  leave  them  to  nature,  "tike  an  extra-uterine  conception"  would  be, 
either  to  consign  the  woman  to  immediate  death,  or  what  is  still  worse,  to  death 
from  protracted  and  torturing  illness.     C. 


259 

symptoms  then  of  abortion,  must  be  those  produced  by  separation 
of  the  ovum,  and  contraction  of  the  uterus.  To  these,  which  are 
essentia],  may  be  added  others  more  accidental,  induced  by  them, 
and  varying  according  to  the  constitution  and  habits  of  die  patient. 
The  ovum  may  be  thrown  off  at  different  stages  of  its  growth  ; 
and  the  symptoms,  even  at  the  same  period,  vary  in  duration  and 
degree.  The  process  of  gestation  may  be  checked,  even  before 
the  foetus  or  vesicular  part  of  the  ovum  has  descended  into  the 
uterus,  or,  at  least,  can  be  readily  detected,  and  when  the  decidua 
only  is  formed.  In  this  case,  which  occurs  within  three  weeks  af- 
ter impregnation,  the  symptoms  are  much  the  same  with  those  of 
menorrhagia.  There  is  always  a  considerable,  and  often  a  copious 
discharge  of  blood,  which  coagulates  or  forms  clots.  This  is  ac- 
companied with  marks  of  uterine  irritation,  such  as  pain  in  the 
back  and  loins,  frequently  spasmodic  affections  of  the  bowels,  and 
occasionally  a  slight  febrile  state  of  the  system.  In  plethoric  ha- 
bits, and  when  abortion  proceeds  from  over-action,  or  hemorrhagic 
action  of  the  uterine  vessels,  the  fever  is  idiopathic,  and  precedes 
the  discharge.  In  other  circumstances  it  is  either  absent,  or,  when 
present,  it  is  symptomatic,  and  still  more  inconsiderable,  arising 
merely  from  pain  or  irritation.  As  the  deciduous  vessels  are  very 
small,  and  are  soon  displaced,  they  cannot  be  detected  in  the  dis- 
charge. Nothing  but  coagulum  can  be  perceived ;  and  this,  as  in 
other  cases  of  uterine  hemorrhage,  is  often  so  firm,  and  the  glo- 
bules and  lymph  so  disposed,  as  to  give  it,  more  especially  if  it 
have  been  retained  for  some  time  about  the  uterus  or  vagina,  a 
streaked  or  fibrous  appearance,  which  sometimes  gives  rise  to  a 
supposition,  that  it  is  an  organized  substance. 

The  only  interruption  to  the  discharge  in  this  case  of  abortion, 
proceeds  from  the  formation  of  clots,  which,  however,  are  soon 
displaced.  Women,  if  plethoric,  sometimes  suffer  considerably 
from  the  profusion  of  the  discharge  ;  but,  in  general,  they  soon 
recover. 

II  the  ovum  have  descended  into  the  uterus,  and  acquired  the 
size  of  a  nut,  the  symptoms  are  somewhat  different.  We  have  an 
attempt  in  the  uterus  to  contract,  which  formerly  was  not  necessa- 


260 

ry  ;  we  have  pains  more  or  less  regular  in  the  hack  and  hypogas- 
tric region ;  we  have  more  disturbance  of  the  abdominal  viscera, 
particularly  the  stomach.  The  discharge  is  copious,  and  small  bits 
of  fibrous  substance  can  often  be  observed.  Sometimes  the  vesi- 
cle may  be  detected  in  the  first  discharge  of  blood,  and  will  be 
found  to  be  streaked  over  with  pale  vessels,  giving  it  an  appear- 
ance as  if  it  had  been  slightly  macerated.  When  all  the  contents 
are  expelled,  a  bloody  discharge  continues  for  a  few  hours,  and  is 
then  succeeded  by  a  serous  fluid.  At  this  time,  and  in  later  abor- 
tion, if  the  symptoms  take  place  gradually,  we  may  sometimes  ob- 
serve a  gelatinous  matter  to  come  away  before  the  hemorrhage 
appears. 

If  the  uterus  contain  more  vascular  and  organized  matter,,  as  in 
the  beginning  of  the  third  month,  the  vesicle  never  escapes  first ; 
but  we  have  for  some  time  a  discharge  of  blood,  accompanied  or 
succeeded  by  uterine  pain.  Then  the  inferior  part  or  short  stalk 
of  the  ovum  may  be  expelled,  gorged  with  blood,  and  afterwards 
the  upper  part  equally  injured.  Sometimes  the  whole  comes  away 
at  once  and  entire  ;  but  this  is  rare.  As  considerable  contraction 
is  now  required  in  the  uterus,  the  pains  are  pretty  severe.  The 
derangement  of  the  stomach  is  also  greater  than  formerly,  giving 
rise  to  sickness  or  faintness,  which  is  a  natural  contrivance  for 
abating  the  hemorrhage. 

When  the  membranes  come  to  occupy  more  of  the  uterus,  and 
a  still  greater  difference  exists  betwixt  the  placenta  and  decidua, 
we  have  again  a  change  of  the  process ;  we  have  more  bearing- 
down  pain,  and  greater  regularity  in  its  attack  ;  we  have  a  more 
rapid  discharge,  owingto  the  greater  size  of  the  vessels;  but  there  is 
not  always  more  blood  lost  now  than  at  an  earlier  period,  for  coagula 
form  readily  from  temporary  fits  of  faintness,  and  other  causes,  and 
interrupt  the  flow  until  new  and  increased  contraction  displaces 
them.  Often  the  membranes  give  way,  and  the  foetus  escapes 
with  the  liquor  amnii,  whilst  the  rest  of  the  ovum  is  retained  for 
some  hours  or  even  days,*  when  it  is  expelled  with  coagulated 

*  In  all  cases  the  placenta  is  retained  much  lonjer  after  the  expulsion  of  the 
•T^iild  in  abortion,  than  in  labour  at  the  full  timei 


261 

blood  separating  and  confounding  its  different  parts  or  layers. 
Retention  of  the  seeundincs,  when  accompanied  with  considerable 
or  repeated  hemorrhage,  very  generally  is  dependent  on,  or  con- 
nected with,  spasmodic  contraction  of  the  uterus,  which  embraces 
a  very  small  bit  of  the  upper  part  of  the  placenta.  At  other  times 
the  fcetal  and  maternal  portions  separate,  and  the  first  is  expelled 
before  the  second,  forming  a  very  beautiful  preparation.  In  some 
rare  instances  we  find  the  whole  ovum  expelled  entire,  and  in  high 
preservation.  After  the  expulsion,  the  hemorrhage  goes  off,  and 
is  succeeded  by  a  discharge,  somewhat  resembling  the  lochia. 

In  cases  of  twins,  after  one  child  is  expelled,  either  alone  or 
with  its  secundines,  the  discharge  sometimes  stops,  and  the  wo- 
man continues  pretty  well  for  some  hours,  or  even  for  a  day  or 
two,  when  a  repetition  of  the  process  takes  place,  and  if  she  has 
been  usiug  any  exertion,  there  is  generally  a  pretty  rapid  and  pro- 
fuse discharge.  This  is  one  reason,  amongst  many  others,  for  con- 
fining women  to  bed  for  several  days  after  abortion. 

There  is  frequently,  for  a  longer  or  shorter  time  before  the  com- 
mencement of  abortion,  a  pain  and  irregular  action  in  the  neigh- 
bouring parts,  which  give  warning  of  its  approach,  before  either 
discharge  or  contraction  takes  place  ;*  unless  when  it  proceeds  from 
violence,  in  which  case  the  discharge  may  instantly  appear.  This 
is  the  period  at  which  we  can  most  effectually  interfere  for  the 
prevention  of  abortion.  I  need  not  be  particular  in  adding,  that 
we  are  not  to  confound  these  symptoms  with  the  more  chronic  ail- 
ments which  accompany  pregnancy. 

A  great  diversity  obtains  in  different  instances  with  regard  to 
the  symptoms  and  duration  of  abortion.  In  some  cases  the  pains 
are  very  severe  and  long  continued ;  in  others  short  and  trifling  : 
nor  is  the  degree  of  pain  always  a  correct  index  of  the  force  of 
conn-action.  Sometimes  the  hemorrhage  is  profusef  and  alarm- 
ing ;  at  other  times,  although  circumstances  may  not  be  apparent- 

*  In  some  cases,  shooting  pains  and  tension  are  felt  in  the  breasts  before  abor- 
tion, and  the  patient  is  feverish. 

t  Those  who  are  plethoric  generally  lose  much  blood,  unless  the  contraction 
have  been  brisk.  In  some  case9  six  or  seven  pounds  of  blood  have  been  lost  in  a 
few  hour? 


262 

\y  very  different,  it  is  moderate  or  inconsiderable.  Often  the  sym- 
pathetic effects  on  the  stomach  and  bowels  are  scarcely  produc- 
tive of  inconvenience,  whilst  in  a  greater  number  of  instances  they 
are  very  prominent  symptoms. 

I  may  only  add,  that,  cateris  paribus,  we  shall  find,  that  the 
farther  the  pregnancy  is  advanced  beyond  the  third  month,  and 
the  nearer  it  approaches  to  the  end  of  the  sixth,  the  less  chance  is 
there  of  abortion  being  accompanied,  but  the  greater  of  its  being 
succeeded  by  nervous  affection. 

As  there  is  a  diversity  in  the  symptoms,  so  is  there  also  in  the 
duration  of  abortion  ;  for,  whilst  a  few  hours  in  many,  and  not 
above  three  days  in  the  majority  of  cases,  is  sufficient  to  complete 
the  process,  we  find  other  instances  in  which  it  is  threatened  for  a 
long  time,  and  a  number  of  weeks  elapse  before  the  expulsion  take 
place. 

In  some  cases  the  child  appears  to  be  dead  for  a  considerable 
time  before  the  symptoms  which  accompany  expulsion  occur. 
But  in  a  great  majority  of  cases  it  is  living,  when  the  first  signs  of 
abortion  are  perceived,  and  in  some  instances  is  born  alhe.  The 
signs  by  which  we  judge  that  the  child  in  utero  is  dead,  are  the 
sudden  cessation  of  the  morning  sickness,  or  of  any  other  sympa- 
thetic system  which  may  have  been  present.  The  breasts  become 
flaccid.  If  milk  had  been  formerly  secreted,  it  sometimes  disap- 
pears, but  in  other  instances  the  contrary  happens,  and  no  evident 
secretion  takes  place  until  the  action  of  gestation,  or  at  least  the 
life  of  the  child  be  lost.  In  almost  every  case,  however,  the  breasts 
will  be  found  to  have  lost  their  firmness.  If  the  pregnancy  had 
advanced  beyond  the  period  of  quickening,  the  motion  of  the  child 
will  be  lost,  and  a  feeling  of  heaviness  will  be  felt  about  the  pelvis. 
AVhen  all  these  signs  are  observed,  and  when  they  are  followed  by 
discharge,  and  especially  when  this  is  attended  with  pain,  there 
can  be  no  doubt  that  expulsion  will  take  place,  and  it  would  be  im- 
proper to  prevent  it.  We  are  not,  however,  to  conclude  that  the 
child  is  dead,  merely  because  it  does  not  move  ;  and  when  abortion 
is  threatened  before  the  term  of  quickening,  this  sign  cannot  enter 
into  our  consideration. 


263 

When  the  ovum  perishes  at  a  very  early  period,  and  is  not  im- 
mediately discharged,  we  find  that  the  sympathetic  signs  of  preg- 
nancy disappear,  and  not  unfrequently  a  serous  or  milky  fluid 
comes  from  the  nipples.  The  woman  feels  languid  and  hot  at 
night,  or  has  fits  of  sickness,  or  hysterical  symptoms;  a  discharge 
of  foetid  dark  coloured  fluid  takes  place  from  the  vagina,  and  is 
often  mixed  with  particles  like  snuff.  This  continues  till  all  the 
remains  of  the  ovum  have  come  away,  and  then  the  health  and 
spirits  are  restored. 

If,  at  a  more  advanced  period,  the  ovum  remain  after  the  child 
dies,  it  is  converted  either  into  a  mole  or  hydatids ;  and  this  may 
also  happen  even  at  a  very  early  stage  of  pregnancy.  These  cases 
have  already  been  considered.  It  is  generally  most  prudent  to  ob- 
viate symptoms,  and  wait  until  the  os  uteri  open  and  pains  come 
on.  Then  we  are  to  be  directed  by  existing  circumstances.  Whe- 
ther the  ovum  becomes  putrid,  or  undergo  a  change  into  hydatids, 
it  is  reasonable  to  expect  that  the  vessels  of  the  uterus,  being  no 
longer  employed  in  the  growth  of  the  foetus,  should  diminish,  and 
become,  in  the  first  case,  merely  sufficient  to  nourish  the  uterus ; 
and,  in  the  second,  to  apply  the  necessities  of  the  substance  at- 
tached to  the  inner  surface  of  the  womb ;  for  there-  is  a  commu- 
nication between  them,  and  a  discharge  of  blood  attends  the  ex- 
pulsion of  either  a  mole  or  hydatids;  whereas,  on  the  other  hand, 
if  the  ovum  has  perished  completely  and  become  putrid,  the  dis- 
charge is  rather  a  foetid  sanies  than  red  blood. 

Abortion  may  very  properly  be  divided  into  accidental  and  ha- 
bitual. The  exciting  causes  of  the  first  class  may,  in  general,  be 
easily  detected ;  those  giving  rise  to  the  second  are  often  more 
obscure ;  and,  without  great  attention,  the  woman  will  go  on  to 
miscarry,  until  either  sterility,  or  some  fatal  disease,  be  induced. 

In  many  cases,  there  can  be  no  peculiar  predisposing  cause  of 
abortion ;  as,  for  instance,  when  it  is  produced  by  blows,  rupture 
of  the  membranes,  or  accidental  separation  of  the  decidua ;  but 
when  it  occurs  without  any  very  perceptible  exciting  cause,  it  is 
allowable  to  infer,  that  some  predisposing  state  exists ;  and  this 
frequently  consists  in  an  imperfect  mode  of  uterine  action,  induced 
by  age,  former  miscarriages,  and  other  causes.     Tt  is  w^ll  known. 


264 

that  women  can  only  tear  children  until  a  certain  age ;  after  whichy 
the  uterus  is  no  longer  capable  of  performing  the  action  of  gesta- 
tion, or  of  performing  it  properly.  Now,  it  is  observable,  that  this 
incapability  or  imperfection  takes  place  sooner  in  those  who  are 
advanced  in  life  before  they  marry,  than  in  those  who  have  mar- 
ried and  begun  to  bear  children  earlier.  Thus  we  find,  that  a  wo- 
man who  marries  at  forty,  shall  be  very  apt  to  miscarry;  whereas, 
had  she  married  at  thirty,  she  might  have  born  children  when  older 
than  forty;  from  which  it  may  be  inferred,  that  the  organs  of 
generation  lose  their  power  of  acting  properly  sooner,  if  not  em- 
ployed, than  in  the  connubial  state.  The  same  cause  which  tends 
to  induce  abortion  at  a  certain  age  in  those  who  have  remained 
until  that  time  single,  will  also,  at  a  period  somewhat  later,  induce 
it  in  those  who  have  been  younger  married ;  for  in  them  we  find, 
that,  after  bearing  several  children,  it  is  not  uncommon  to  con- 
clude with  an  abortion  ;  or,  sometimes  after  this  incomplete  action, 
the  uterus,  in  a  considerable  time,  recruits,  as  it  were,  and  the 
woman  carries  a  child  to  the  full  time,  after  which  she  ceases  to 
conceive. 

In  the  next  place,  I  mention  that  one  abortion  paves  the  way 
for  another;  because,  setting  other  circumstances  aside,  it  gives 
the  uterus, a  tendency  to  stop  its  action  of  gestation  at  an  early  pe- 
riod after  conception,  and  therefore  it  is  difficult  to  make  a  woman 
go  to  the  full  time,  after  she  has  miscarried  frequently.  This  fact 
has  also  been  explained  upon  the  principle  of  repeated  abortion 
weakening  the  uterus,*  and  this  certainly  may  have  some  influence. 
The  renewed  operation  of  those  causes  which  formerly  induced 
abortion,  may  likewise  account  in  many  cases  for  its  repetition. 
But  I  am  also  inclined  to  attribute  the  recurrence,  sometimes,  to 
habit  alone,  by  which  I  understand  that  tendency  which  a  part  has 
to  repeat  or  continue  those  modes  of  acting  which  it  lias  frequently 
performed,  as  we  see  in  many  diseases  of  the  stomach  and  wind- 
pipe ;  spasmodic  affections  of  these  and  other  organs,  being  apt  to 

*Perlianc  vero  consuetudiiiem  nihil  aliud  intelligo,  quam  pravam  vasorum 
.uteri  laxitatem  et  inde  provenientem  humorum  stagnaiionem,  ex  abortiendi  la.-- 
bore  sxpius  repetito  inductam."    Hoffmas,  Tom.  iii.  p.  180. 


265 

return  at  the  same  hour,  for  a  long  time.  With  regard  to  the  ute- 
rus, one  remarkable  instance  is  related  by  Schulzius,  of  a  woman, 
who,  in  spite  of  every  remedy,  miscarried  twenty-three  times  at 
the  third  month.  In  this,  and  similar  cases,  slighter  causes  applied 
at  the  period  when  abortion  formerly  happened,  will  be  sufficient 
to  induce  it,  than  would  be  required  at  another  time. 

We  also  find  that  an  excessive  or  indiscriminate  use  of  venery, 
either  destroys  the  power  of  the  organs  of  generation  altogether, 
making  the  woman  barren,  or  it  disposes  to  abortion,  by  enfeebling 
these  organs. 

Some  slight  change  of  structure  in  part  of  the  uterus,  by  influ- 
encing its  actions,  may,  if  it  do  not  prevent  conception,  interfere 
with  the  process  of  gestation,  and  produce  premature  expulsion. 
If,  however,  the  part  affected  be  very  small,  and  near  the  os  uteri, 
it  is  possible  for  pregnancy  to  go  on  to  the  full  time.  Indeed,  it 
generally  does  go  on,  and  the  labour,  as  may  be  foreseen,  will  be 
very  tedious  ;  but  the  operation  of  cutting  the  indurated  os  uteri, 
which  has  been  proposed,  is  seldom  necessary.  1  have  known  one 
instance,  in  which  a  very  considerable  part  of  the  uterus,  I  may  say 
almost  the  whole  of  it,  was  found,  after  delivery,  to  be  extremely 
hard,  and  nearly  ossified:  but  this  state  could  not  have  existed  be- 
fore impregnation  took  place,  for  I  cannot  conceive  that  so  great  a 
proportion  of  the  uterus  should  have  been  originally  diseased,  and 
yet  that  conception,  and  its  consequent  actions,  should  take  place ; 
but  there  is  less  difficulty  in  supposing  that,  during  the  enlarging  of 
the  uterus,  the  vessels  deposited  osseous  or  cartilaginous  matter,  in- 
stead of  muscular  fibres. 

A  general  weakness  of  the  system,  which  must  affect  the  actions 
of  the  uterus,  in  common  with  those  of  other  organs,  is  likewise  to 
be  considered  as  giving  rise  to  abortion,  though  not  so  frequently 
as  was  at  one  time  supposed. 

A  local  weakness  of  the  uterus  sometimes  exists  when  the  ge- 
neral system  is  not  very  feeble ;  or  when  the  constitution  is  deli- 
cate, the  uterus  may  be  weaker  in  proportion  than  other  organs. 
In  this  case,  it  cannot  perform  its  function  with  the  necessary  acti- 
vity and  perfection,  but  it  is  very  apt,  after  a  time,  to  flag.  We 
cannot  operate  with  medicines  directly  upon  the  womb,  for  the 

35 


266 

purpose  of  strengthening  it,  but  must  act  on  it  by  invigorating  the 
general  system,  and  attending  to  all  the  other  functions.  Sea- 
bathing is  of  great  service;  and  after  impregnation,  every  exciting 
cause  of  abortion  must  be  guarded  against.  Women  of  this  de- 
scription are  generally  pale,  of  a  weakly,  flabby  habit,  and  subject 
to  irregular,  often  to  copious  menstruation,  or  fluor  albus.  When 
they  conceive,  the  cold  bath,  light,  digestible  food,  open  bowels, 
and  free  air,  should  be  enjoined ;  and  if  any  uneasy  sensation  be 
felt  about  the  uterus  or  back,  or  the  pulse  throb,  a  little  blood 
should  be  slowly  taken  away,  and  the  woman  keep  her  room  for 
some  days.  Bleeding  prevents  the  womb  from  being  oppressed, 
and  it  is  as  necessary  to  attend  to  this,  as  it  is  to  prevent  the  sto- 
mach from  being  loaded  in  a  dyspeptic  patient.  But,  on  the  other 
hand,  were  we  to  bleed  copiously,  we  might  injure  the  action  of 
the  uterus,  and  destroy  the  child. 

It  has  been  supposed  that  abortion  might  arise  from  a  rigidity  of 
the  uterus,  which  prevented  its  distention.  But  the  uterus  does 
not  distend  like  a  dead  part,  upon  which  pressure  is  applied,  but  it 
grows,  and  therefore  I  apprehend  that  an  effect  is  here  considered 
as  a  primary  cause. 

The  uterus  is  not  only  affected  by  the  general  conditions  of  the 
system,  more  especially  with  regard  to  sensibility,  and  the  state  of 
the  blood  vessels  ;  but  it  likewise  sympathizes  with  the  principal 
organs,  and  may  undergo  changes  in  consequence  of  alterations 
in  their  state. 

Thus  we  often  find  that  loss  of  tone,  or  diminished  action  of 
the  stomach,  produces  amenorrhoea ;  and  it  may  also  on  the  same 
principle  induce  abortion;  on  the  other  hand,  the  action  of  the 
uterus  may  influence  that  of  other  viscera,  as  we  see  in  pulmonary 
consumption,  which  is  sometimes  suspended  in  its  progress  during 
pregnancy ;  or,  if  there  be  any  disposition  in  an  organ  to  disease, 
frequent  abortion,  partly  by  sympathy  betwixt  the  uterus  and  that 
organ,  and  partly  by  the  weakness  which  it  induces,  and  the  gene- 
ral injury  which  it  does  to  the  system  at  large,  may  excite  the  ir- 
regular or  morbid  action  of  the  organ  so  disposed. 

As  the  action  of  the  uterus  is  increased  during  pregnancy,  it 
must  require  more  nervous  energy ;  but  the  size  of  the  nerves  of 


.     267 

the  uterus  is  not  increased  in  proportion  to  the  action;  we  must 
therefore  depend  for  the  increased  supply  upon  the  trunks,  or  lar- 
ger portion  of  the  nervous  substance,  from  which  they  arise ;  for 
we  well  know  that  the  quantity  of  energy  expended  in  an  organ, 
does  not  depend  upon  the  size  of  the  nerve  in  its  substance,  but 
on  the  trunk  which  furnishes  it.  Whenever  action  is  increased  in 
an  organ,  it  must  either  perish,  or  the  larger  nerve  must  send  the 
branches  more  energy;  for  the  branches  themselves  cannot  form 
it,  their  extremities  being  only  intended  for  expending  it;  from 
which  it  follows,  that  in  pregnancy  there  must  be  more  energy 
sent  to  the  uterus,  and  less  to  some  other  part. 

This  is  the  case  with  all  organs  whose  action  is  increased,  other 
parts  being  deprived  in  proportion  as  they  are  supplied,  except 
when  irritation  raises  general  action  above  the  natural  degree  ;  the 
consequence  of  which  is  that  the  power  is  not  sufficient  for  the 
action,  which  becomes  irregular,  and  the  system  is  exhausted,  as 
we  see  in  febrile  conditions. 

There  being  increased  action  of  the  uterus  in  gestation,  requir- 
ing an  increased  quantity  of  energy  to  support  it,  we  find  that  the 
system  is  put  pro  tempore  into  an  artificial  state,  and  obliged  either 
to  form  more  energy,  which  cannot  be  so  easily  done,  or  to  spend 
less  in  some  other  part.  Thus  the  function  of  nutrition,  or  the 
action  by  which  organic  matter  is  deposited,  in  room  of  that  which 
is  absorbed,  often  yields,  or  is  lessened,  and  the  person  becomes 
emaciated,  or  the  stomach  has  its  action  diminished,  or  the  bowels, 
producing  costiveness  and  inflation.  If  no  part  give  way,  and  no 
more  energy  than  usual  be  formed,  gestation  cannot  go  on,  or  goes 
on  imperfectly.  Hence  some  women  have  abortion  induced  by 
being  too  vigorous  ;  that  is  to  say,  all  the  organs  persist  in  keeping 
up  their  action  in  perfection  and  complete  degree. 

A  tendency  to  abortion  also  results  from  a  contrary  cause,  from 
organs  yielding  too  readily,  allowing  the  uterus  to  act  too  easily. 
In  this  state  it  is  as  liable  to  go  wrong,  as  the  general  system  is 
when  it  is  at  the  highest  degree  of  action  compatible  with  health  ; 
the  most  trifling  cause  deranges  it.  Thus,  sometimes,  the  intes- 
tines yield  too  readily,  and  become  almost  torpid,  so  that  a  stool 
can  with  difficulty  be  procured*     Here  costiveness  is  not  a  cause 


268 

of  abortion,  though  it  may  be  blamed.  In  like  manner,  the  mus- 
cular system  may  yield  and  become  enfeebled;  and  in  this  in- 
stance, debility  is  accused  as  the  cause  of  abortion,  although  it  be, 
indeed,  only  an  effect  of  too  much  energy  being  destined  for 
the  uterus.  In  this  case,  the  woman  is  always  weaker  during 
menstruation  and  gestation  than  at  other  times. 

If  the  neighbouring  parts  do  not  accommodate  themselves  to  the 
changes  in  the  direction  of  energy,  and  act  in  concert  with  the 
uterus,  their  action  becomes  irregular,  and  consequently  painful. 
In  this  case,  the  uterus  may  have  its  just  degree  of  power  and  ac- 
tion; but  other  parts  may  not  be  able  to  act  so  well  under  the 
change  of  circumstances.  This  is  chiefly  the  case  in  early  gesta- 
tion, for,  by  time,  the  parts  come  to  act  better.  It  often  gives  rise 
to  unnecessary  alarm,  being  mistaken  for  a  tendency  to  abortion ; 
but  the  symptoms  are  different.  The  pain  is  felt  chiefly  at  night, 
a  time  at  which  weakened  parts  always  suffer  most;  it  returns 
pretty  regularly  for  several  weeks,  but  the  uterus  continues  to  en- 
large, the  breasts  to  distend,  and  all  things  are  as  they  ought  to  be,  if 
we  except  the  presence  of  the  pain.  This  may  be  alleviated  by 
bleeding,  and  sometimes  by  anodynes ;  but  can  only  be  cured  by 
time,  and  avoiding,  by  means  of  rest  and  care,  any  additional  in- 
jury to  parts  already  irregular  and  ticklish  in  the  performance  of 
their  actions.  If  this  be  neglected,  they  will  re-act  on  the  uterus 
at  last,  and  impede  its  function.  It  is  therefore  highly  necessary, 
especially  in  those  disposed  to  abortion,  to  pay  attention  to  pains 
about  the  back,  loins,  or  pubis ;  and  to  insist  upon  rest,  open  bowels, 
and  detracting  blood,  if  the  state  of  the  vascular  system  indicate 
evacuation. 

Even  although  the  different  organs,  both  near  and  remote,  may 
have  accommodated  themselves  to  the  changes  in  the  uterine  ac- 
tion, in  the  commencement  of  gestation,  the  proper  balance  may 
yet  be  lost  at  a  subsequent  period ;  and  this  is  most  apt  to  take 
place  about  the  end  of  the  third,  or  beginning  of  the  fourth  month, 
before  the  uterus  rises  out  of  the  pelvis  :  and  hence  a  greater  num- 
ber of  abortions  take  place  at  that  time  than  at  any  other  stage  of 
pregnancy.  There  is  from  that  time  to  the  period  of  quickening, 
a  greater  susceptibility  in  the  uterus  to  have  its  action  interrupted. 


269 

than  either  before  or  afterwards;  which  points  out  the  necessity  of 
redoubling  our  vigilance  in  watching  against  the  operation  of  any  of 
the  causes  giving  rise  to  abortion  from  the  tenth  to  the  sixteenth 
week. 

If  the  action  of  gestation  go  on  under  restraint,  as  for  instance, 
by  a  change  of  position  in  the  uterus,  or  by  its  prolapsing  too  low 
in  the  vagina,  it  is  very  apt  to  be  accompanied  by  uneasy  feelings, 
for,  whenever  any  action  is  constrained,  sensation  is  produced.  The 
woman  feels  irregular,  and  pretty  sharp  pain  in  the  region  of  the 
uterus,  and  from  sympathetic  irritation  both  the  bladder  and  rectum 
may  be  affected,  and  occasionally  a  difficulty  is  felt  in  making  wa- 
ter, by  which  a  suspicion  is  raised  that  retroversion  is  taking  place. 
Sometimes  the  cervical  vessels  in  these  circumstances  yield  a  little 
blood,  as  if  abortion  were  going  to  happen ;  but  by  keeping  the  pa- 
tient at  rest,  and  attending  to  the  state  of  the  rectum  and  bladder,  no 
harm  is  done ;  and  when  the  uterus  rises  out  of  the  pelvis,  no  farther 
uneasiness  is  felt.  Occasionally  a  pretty  considerable  discharge  may 
take  place  under  these  circumstances,  if  the  vascular  system  be  full, 
or  the  vessels  about  the  cervix  large.  But,  by  care,  gestation  will 
go  on ;  for  discharge  alone  does  not  indicate  that  abortion  must  ne- 
cessarily happen.  It,  indeed,  often  causes  abortion,  and  is  almost 
always  an  attendant  upon  it ;  but  we  form  our  judgment,  not  from 
this  symptom  alone,  but  also  from  the  state  of  the  muscular  fibres, 
and  the  vitality  of  the  child. 

Retroversion  of  the  uterus  likewise  constrains  very  much  its  ac- 
tion, and  may  give  rise  to  abortion,  though  in  a  greater  number  of 
instances,  by  care,  gestation  will  go  on,  and  the  uterus  gradually 
ascend.  The  bowels  are  to  be  kept  open,  and  the  urine  regularly 
evacuated. 

Sometimes  in  irritable  or  hysterical  habits,  the  process  of  gesta- 
tion produces  a  considerable  degree  of  disturbance  in  the  actions 
of  the  abdominal  viscera,  particularly  the  stomach ;  exciting  fre- 
quent and  distressing  retching  or  vomiting,  which  may  continue  for 
a  week  or  two,  and  sometimes  is  so  violent,  as  to  invert  the  peri- 
staltic motion  of  the  intestines  near  the  stomach,  in  which  case  fe- 
culent matter,  and,  in  some  instances,  lumbrici  are  vomited. 

This  affection  is  often  accompanied  by  an  unsettled  state  of 


270 

mind,  which  adds  greatly  to  the  distress.  We  sometimes,  in  these 
circumstances,  have  painful  attempts  made  by  the  muscles  to  force 
the  uterus  downward,  and  these  are  occasionally  attended  by  a 
very  slight  discharge  of  blood.  We  have,  however,  no  regular 
uterine  pain ;  and  if  we  are  careful  of  our  patient,  abortion  is  rarely 
produced. 

The  best  practice  is  to  take  away  a  little  blood  at  first,  to  keep 
the  bowels  open,  to  lessen  the  tendency  to  vomit,  by  applying 
leeches,  or  an  opium  plaster,  or  a  small  blister,  to  the  region  of  the 
stomach,  and  to  allay  pain  by  doses  of  hyoscyamus  or  opium,  con- 
joined with  carminatives.  When  the  mind  is  much  affected,  or  the 
head  painful,  it  is  proper  to  shave  the  head,  and  wash  it  frequently 
with  cold  vinegar,  or  apply  leeches  to  the  temples ;  at  the  same 
time  we  keep  the  patient  very  quiet,  and  have  recourse  to  a  sooth- 
ing management. 

The  uterus  being  a  large  vascular  organ,  is  obedient  to  the  laws 
of  vascular  action,  whilst  the  ovum  is  more  influenced  by  those  re- 
gulating new-formed  parts;  with  this  difference,  however,  that  new- 
formed  parts  or  tumours  are  united  firmly  to  the  part  from  which 
they  grow  by  all  kinds  of  vessels,  and  generally  by  fibrous  or  cel- 
lular substance,  whilst  the  ovum  is  connected  to  the  uterus  only  by 
very  tender  and  fragile  arteries  and  veins.  If,  therefore,  more  blood 
be  sent  to  the  maternal  part  of  the  ovum,  than  it  can  easily  receive 
and  circulate  and  act  under,  rupture  of  the  vessels  will  take  place, 
and  an  extravasation  and  consequent  separation  be  produced  ;  or, 
even  when  no  rupture  is  occasioned,  the  action  of  the  ovum  may 
be  so  oppressed  and  disordered,  as  to  unfit  it  for  continuing  the 
process  of  gestation.  There  must,  therefore,  be  a  perfect  corres- 
pondence betwixt  the  uterus  and  the  ovum,  not  only  in  growth 
and  vascularity,  but  in  every  other  circumstance  connected  with 
their  functions. 

Even  when  they  do  correspond,  if  the  uterus  be  plethoric,  the 
ovum  must  also  be  full  of  blood,  and  rupture  is  very  apt  to  take 
place.  This  is  a  frequent  cause  of  abortion,  more  especially  in 
those  who  menstruate  copiously.  On  the  other  hand,  when  the 
uterus  is  deficient  in  vascularity,  which  often  happens  in  those  who 
menstruate  sparingly  or  painfully,  or  who  have  the  menses  pretty 


271 

abundant,  but  watery,  the  child  generally  dies  before  the  seventh 
month,  and  is  expelled.  The  process  is  prematurely  and  imper- 
fectly finished. 

The  existence  of  plethora  is  to  be  considered  as  a  very  frequent 
cause  of  abortion,  and  requires  most  particular  attention.  It  more 
especially  obtains  in  the  young  and  vigorous,  or  in  those  who  live 
luxuriously,  and  sleep  in  soft  warm  beds.  It  renders  the  uterus  too 
easily  supplied  with  blood  :  the  increase  is  not  made  in  the  regular 
degree,  corresponding  to  the  gradual  increase  of  action,  and  aug- 
mentation of  size  ;  but  it  is,  if  I  may  use  the  expression,  forced  on 
the  uterus,  which  is  thus  made  for  a  time  to  act  strongly  and  ra- 
pidly. This  action  is  sometimes  so  great,  that  the  person  feels 
weight  in  the  region  of  the  uterus,  and  shooting  pains  about  the 
pelvis ;  but,  in  other  instances,  the  vessels  suddenly  give  way,  with- 
out previous  warning,  and  the  blood  bursts  forth  at  the  os  uteri. 
This  cause  is  especially  apt  to  operate  in  those  who  are  newly  mar- 
ried, and  who  are  of  a  salacious  disposition,  as  the  action  of  the 
uterus  is  thjps  much  increased,  and  the  existence  of  plethora  ren- 
dered doubly  dangerous.  In  these  cases,  whenever  the  menses 
have  become  obstructed,  all  causes  tending  to  increase  the  circula- 
tion must  be  avoided,  and  often  a  temporary  separation  from  the 
husband  is  indispensable.  Often  do  we  find  that  slight  exertion, 
within  a  fortnight  after  the  menses  stop,  will  produce  a  speedy  and 
violent  eruption  of  blood,  which  continues  until  the  vessels  are  fully 
unloaded,  and  until  all  that  part  of  the  process  of  forming  an  ovum 
which  has  been  affected,  be  undone. 

Abortion  necessarily  implies  separation  of  the  ovum,  which  may 
be  produced  mechanically,  or  by  spontaneous  rupture  of  the  ves- 
sels, or  by  an  affection  of  the  muscular  fibres.  It  unavoidably  re- 
quires, for  its  accomplishment,  contraction  of  those  fibres  which 
formerly  were  in  a  dormant  state.  A  natural  and  necessary  effect 
of  this  contraction  is  to  develop  the  cervix  uteri.  This,  when  ges- 
tation goes  on  regularly,  is  accomplished  gradually  and  slowly  by 
the  extension  and  formation  of  fibres.  In  abortion  no  fibres  are 
formed ;  but  muscular  action  does  all,  except  in  those  instances 
where  the  action  of  gestation  goes  on  irregularly  and  too  fast ;  in 
which  case,  the,  cervix  distends,  sometimes  by  the  third  month,  by 


272 

the  same  process  which  distends  the  fundus.  But  much  more  fre- 
quently the  cervix  only  relaxes  during  abortion,  as  the  os  uteri 
does  in  natural  labour,  and  yields  to  the  muscular  action  of  the  fun- 
dus, or  distended  part. 

The  existence  and  growth  of  the  foetus  depend  on  the  foetal  por- 
tion of  the  ovum.  The  means  of  nourishment,  and  the  accommoda- 
tion of  the  foetus  in  respect  of  lodgment,  depend  on  the  uterus  ;  and 
these  circumstances  requiring  both  foetal  and  maternal  action,  are 
intimately  connected.  The  condition  of  the  uterus  qualifying  it  to 
enlarge,  to  continue  the  existence  and  operation  of  the  maternal 
portion  of  the  placenta  or  ovum,  and  to  transmit  blood  to  the  ovum, 
exactly  in  the  degree  correspondent  to  its  want,  constitutes  the  ac- 
tion of  gestation  When  the  action  of  gestation  ceases  universally 
in  the  uterus,  another  action,  namely,  muscular  contraction,  begins, 
and  then  all  hope  of  retaining  the  ovum  any  longer  is  at  an  end. 
I  know  that  we  have  been  told  of  instances  where  contraction,  after 
beginning,  stopped  for  several  weeks.  The  os  uteri  may  be  pre- 
maturely developed ;  it  may  be  open  for  some  weeks,  even  without 
pain  ;  but  no  man  will  say  that,  in  this  case,  labour  or  uterine  con- 
traction has  begun.  We  may  even  have  partial  muscular  action, 
in  a  few  cases,  about  the  os  uteri,  which  has  less  to  do  with  the 
action  of  gestation  than  any  other  part  of  the  uterus ;  and  this  ac- 
tion is  often  attended  with  considerable  pain  or  uneasiness.  Some- 
times it  is  connected  with  convulsive  agitation  of  several  of  the 
external  muscles  of  the  body.  Even  in  this  case,  expulsion  does 
not  always  immediately  take  place  ;  for  by  bleeding,  and  rest,  and 
opiates,  the  motion  may  sometimes  be  checked ;  but  regular  and 
universal  action  of  the  muscular  fibres  never  yet  has  been  stopped. 
It  may,  like  other  muscular  actions,  be  suspended  by  anodynes  or 
artificial  treatment ;  but  it  never  has,  and  never  can  be  stopped, 
otherwise  than  by  the  expulsion  of  the  ovum,  when  a  new  train  of 
actions  commence.  Whenever,  then,  at  any  period  of  pregnancy, 
we  have  paroxysms  of  pain  in  the  back,*  and  region  of  the  uterus, 

*  It  may  not  be  improper  to  mention,  that  in  some  febrile  affections  we  have 
pain  in  the  back  and  loins,  occasionally  remitting  or  disappearing  altogether  for  a 
short  space,  and  then  returning.  Sometimes  along  with  this  we  have,  owing  to 
the  affection  of  the  circulation,  and  in  some  instances,  to  previous  exertion,  a 


273 

more  especially  if  these  be  attended  with  feeling  of  weight  in  thai 
region,  tenesmus,  micturition,  descent  of  the  uterus  in  the  pelvis, 
and  opening  of  the  os  uteri,  we  may  be  sure  that  expulsion,  though 
retarded,  will  soon  take  place.  This  fact  is  not  always  attended 
to  in  abortion,  for  many  think  that  if  by  anodynes  they  can  abate 
the  pain,  they  shall  make  the  woman  go  to  the  full  time. — This  is 
true,  with  regard  to  many  painful  sensations  which  may  attend  a 
threatened  abortion,  or  which  may  be  present,  although  there  be 
no  appearance  of  abortion  ;  but  it  does  not  hold  with  regard  to 
those  regular  pains  proceeding  from  universal  action  of  the  uterine 
fibres ;  and  we  may  save  both  ourselves  and  our  patients  some 
trouble,  by  keeping  this  in  remembrance. 

Seeing,  then,  that  contraction  is  brought  on  by  stopping  the  ac- 
tion of  gestation,  and  that  when  it  is  brought  on  it  cannot  be  check- 
ed, nor  the  action  of  gestation  restored,  we  must  next  inquire  how 
this  action  may  be  stopped.  I  have  already  mentioned  several 
circumstances  affecting  the  uterus,  and  likely  to  injure  its  actions  5 
and  these  I  shall  not  repeat,  but  go  on  to  notice  some  others,  which 
are  often  more  perceptible  :  and  first  I  shall  mention  violence,  such 
as  falls,  blows,  and  much  fatigue,  which  may  injure  the  child,  and 
detach  part  of  the  ovum.  If  part  of  the  ovum  be  detached,  we 
have  not  only  a  discharge  of  blood,  but  also  the  uterus,  at  that  part, 
suffers  in  its  action,  and  may  influence  the  whole  organ,  so  as  to 
stop  the  action  universally.  But  the  time  required  to  do  this  is 
various,  an  opportunity  is  often  given  to  prevent  the  mischief  from, 
spreading,  and  to  stop  any  farther  effusion — perhaps  to  accomplish 
a  re-union. 

Violent  exercise,  as  dancing,  for  instance,  or  much  walking,  or 
the  fatiguing  dissipations  of  fashionable  life,  more  especially  in  the 

discharge  from  the  vessels  about  the  os  uteri.  The  state  is  distinguished  from, 
uterine  contraction,  by  our  finding  that  the  cervix  is  unaffected,  that  the  pains 
are  increased  by  motion  or  pressure,  and  are  more  irregular  than  those  attending, 
labour.  This  state  may  be  prevented  from  inducing  abortion,  by  rest,  by  keep- 
ing  the  bowels  open,  by  anodynes  preceded  by  venesection,  if  the  pulse  indicate 
it.  Frictions,  with  camphorated  spirits  of  wine,  or  laudanum,  give  relief.  Any 
exertion,  during  the  remaining  period  of  gestation,  will  renew  the  pain  in  the. 
Tjack. 


274 

earlier  months,  by  affecting  the  circulation,  may  vary  the  distri- 
bution of  blood  in  the  uterus,  so  much  as  to  produce  rupture  of 
the  vessels,  or  otherwise  to  destroy  the  ovum.  There  is  also  ano- 
ther way  in  which  fatigue  acts,  namely,  by  subducting  action  and 
energy  from  the  uterus :  for  the  more  energy  that  is  expended  on 
the  muscles  of  the  inferior  extremities,  the  less  can  be  afforded  or 
directed  to  the  uterus ;  and  hence  abortion  may  be  induced  at  an 
early  stage  of  gestation.*  Even  at  a  more  advanced  period,  in- 
convenience will  be  produced  upon  the  principle  formerly  men- 
tioned; for  the  nerves  of  the  loins  conveying  less  energy,  in  many 
instances,  though  not  always,  to  the  muscles,  they  are  really  weak- 
er than  formerly,  and  are  sooner  wearied,  producing  pain,  and 
prolonged  feeling  of  fatigue  for  many  days,  after  an  exertion  which 
may  be  considered  as  moderate.  This  feeling  must  not  be  con- 
founded with  a  tendency  to  abortion,  though  it  may  sometimes  be 
combined  with  it,  for  generally  by  rest  the  sensation  goes  off. 
Neither  must  we  suppose  that  the  child  is  dead,  from  its  being 
usually  quiet  during  that  period,  for  as  soon  as  the  uterus,  which 
has  been  a  little  impaired  in  its  action,  recovers,  it  moves  as  strong- 
ly as  ever. 

In  the  next  place  I  mention  the  death  of  the  child,  which  may 
be  produced  by  syphilis,  or  by  diseases,  perhaps,  peculiar  to  itself, 
or  by  that  state  which  produces  too  much  liquor  amnii,  or  by  in- 
jury of  the  functions  of  the  placenta,  which  may  arise  from  an 
improper  structure  of  the  gland  itself,  or  aneurism,  or  other  dis- 
eases of  the  cord.  But  in  whatever  way  it  is  produced,  the  effect 
is  the  same  in  checking  the  action  of  gestation,  unless  there  be 
twins,  in  which  case  it  has  been  known,  that  the  uterus  sometimes 
did  not  suffer  universally,  but  the  action  went  on,  and  the  one 
child  was  born  of  the  full  size,  the  other  small  and  injured.f   The 

*  The  same  effect  is  observable  in  the  stomach  and  other  organs.  If  a  deli- 
cate person,  after  a  hearty  meal,  use  exercise  to  the  extent  of  fatigue,  he  feels 
that  the  food  is  not  digested,  the  stomach  having  been  weakened  or  injured  in 
its  actions. 

f  It  has  even  been  known,  that,  in  consequence  of  the  death  of  one  child,  the 
uterus  has  suffered  partially,  and  expulsion  taken  place ;  but  the  other  child  con- 
tinuing to  live,  has  preserved  the  action  of  gestation  in  that  part  of  the  uterus. 


275 

V 

length  of  time  required  for  producing  abortion  from  this  cause  is 
various;  sometimes  it  is  brought  on  in  a  few  hours;  at  other  times, 
not  for  a  fortnight,  or  even  longer.(c)  In  these  and  similar  cases, 
when  the  muscular  action  is  commencing,  the  discharge  is  trifling, 
like  menstruation,  until  the  contraction  become  greater,  and  more 
of  the  ovum  be  separated.  When  symptoms  of  abortion  proceed 
from  this  cause,  it  is  not  possible  to  prevent  its  completion ;  and 
it  would  be  hurtful  even  if  it  were  possible.  When,  therefore, 
after  great  fatigue,  profuse  evacuations  in  delicate  habits,  violent 
colic,  or  other  causes,  the  motion  of  the  child  ceases,  the  breasts 
become  flaccid,  and  the  signs  of  gestation  disappear,  we  need  not 
attempt  to  retard  expulsion,  but  should  direct  our  principal  atten- 
tion to  conduct  the  woman  safely  through  the  process. 

Another  cause  is,  any  strong  passion  of  the  mind.  The  influence 
of  fear,  joy,  and  other  emotions,  on  the  muscular  system,  is  well 
known;  and  the  uterus  is  not  exempted  from  their  power;  any 
sudden  shock,  even  of  the  body,  has  much  effect  on  this  organ. 
The  pulling  of  a  tooth,  for  instance,  sometimes  suddenly  produces 
abortion.  A  thunder  storm,  or  violent  cannonade,  has  been  sup- 
posed to  cause  abortion  by  the  concussion  of  the  air ;  but  it  is 

which,  properly  speaking,  belonged  to  it,  and  pregnancy  has  still  gone  on.  This, 
however,  is  an  extremely  rare  occurrence ;  for,  in  almost  every  instance,  the 
death  of  one  child  produces  an  affection  of  the  action  of  gestation  in  the  whole 
uterus,  and  the  consequent  expulsion  of  both  children. 

(c)  In  one  instance  that  fell  under  my  notice,  a  lady  who  had  suffered  several 
previous  abortions,  but  who  had  also  borne  two  healthy  living  children,  was  over- 
turned in  a  carriage  before  the  completion  of  the  third  month  of  gestation.  She 
was  extremely  bruised,  and  was,  in  consequence,  confined  to  her  bed  for  several 
days;  yet,  upon  getting  about  again,  she  fancied,  after  the  period  of  quickening, 
that  she  felt  the  motion  of  the  child,  with  all  the  other  symptoms  of  favourable 
and  healthy  pregnancy.  She  thus  went  on  to  the  full  period  of  utero-gestation ; 
and  on  the  very  day  she  calculated,  was  delivered  of  a  foetus  that  certainly  had 
lost  the  principle  of  vitality  for  several  months,  not  appearing  larger  than  an 
embryo  of  five  months.  The  placenta  was  also  almost  exsangueous,  and  appear- 
ed as  if  it  might  have  been  detached  from  the  uterine  parietes  for  some  time. 
Indeed,  the  whole  appeared  like  a  preparation  that  had  been  preserved  in  »p. 
vini,  or  sp.  terebinth.  The  lady  had  a  speedy  recovery,  and,  at  no  distant  pe- 
riod, bore  a  healthy  living  child. 


276 

•more  probable  when  they  have  that  effect,  that  it  is  owing  to  men"1 
tal  trepidation. 

Emmenagogues,  or  acrid  substances,  such  as  savine  and  other 
irritating  drugs,  more  especially  those  which  tend  to  excite  a  con- 
siderable degree  of  vascular  action,  may  produce  abortion. 

Such  medicines,  likewise,  as  exert  a  violent  action  on  the  sto- 
mach or  bowels,  will,  upon  the  principle  formerly  mentioned,  fre- 
quently excite  abortion;  and  very  often  are  taken  designedly  for 
that  purpose  in  such  quantity  as  to  produce  fatal  effects  ;*  hence 
emetics,  strong  purgatives,  diuretics,  or  a  full  course  of  mercury, 
must  be  avoided  during  pregnancy. 

If  any  part  with  which  the  uterus  sympathizes  have  its  action 
greatly  increased  during  pregnancy,  the  uterus  may  come  to  suf- 
fer, and  abortion  be  produced.  Hence  the  accession  of  morbid 
aetion  or  inflammation  in  any  important  organ,  or  on  a  large  extent 
of  cuticular  surface,  may  bring  on  miscarriage,  which  is  one  cause 
why  small-pox  often  excites  abortion,  whilst  the  same  degree  of 
ever,  unaccompanied  with  eruption,  would  not  have  had  that  ef- 
fect. Hence  also  increased  secretory  action  in  the  vagina,  if  to  a 
great  degree,  though  it  may  have  even  originally  been  excited  in 
consequence  of  sympathy  with  the  uterus,  may  come  to  incapacitate 

*  It  is  an  old  observation,  that  those  purgatives  which  produce  much  tenes- 
mus, will  excite  abortion ;  and  this  is  certainly  true,  if  their  operation  be  carried 
to  a  considerable  extent,  and  continue  long  violent.  Hence  dysentery  is  also  apt 
to  bring  on  a  miscarriage.  Those  strong  purges  which  are  sometimes  taken  to 
promote  premature  expulsion,  not  only  act  by  exciting  tenesmus,  but  likewise 
by  inflaming  the  stomach  and  bowels,  and  thus  affect  the  uterus  in  two  ways.  It 
cannot  be  too  generally  known,  that  when  these  medicines  do  produce  abortion, 
the  mother  can  seldom  survive  their  effect.  It  is  a  mistaken  notion,  that  abortion 
can  be  most  readily  excited  by  drastic  purges,  frequent  and  copious  bleeding, 
&c.  immediately  after  the  woman  discovers  herself  to  be  pregnant ;  on  the  con* 
trary,  the  action  of  the  uterus  is  then  more  independent  of  that  of  other  organs, 
and  therefore  not  so  easily  injured  by  changes  in  their  condition.  I  have  already 
shown,  that  abortion  more  frequently  happens  when  the  pregnancy  is  fartiier 
advanced,  because  then  not  only  the  uterus  is  more  easily  affected,  but  the  fatus 
seems  to  suffer  more  readily.  It  is  apt,  either  from  diseases  directly  affecting 
itself,  or  from  changes  in  the  uterine  action,  to  die  about  the  middle  of  the  third 
month,  in  which  case  expulsion  follows  within  a  fortnight. 


277 

the  uterus  for  going  on  with  its  actions,  and  therefore  it  ought  to  be 
moderated  by  means  of  an  astringent  injection. 

Mechanical  irritation  of  the  os  uteri,  or  attempts  to  dilate  it  pre- 
maturely, will  also  be  apt  to  bring  on  muscular  contraction.  At 
the  same  time,  it  is  worthy  of  remark,  that  the  effect  of  such  irri- 
tation is  generally  at  first  confined  to  the  spot  on  which  it  acts,  a 
partial  affection  of  the  fibres  in  the  immediate  vicinity  of  the  os 
uteri  being  all  that  is,  for  some  time,  produced ;  and  therefore 
slight  uneasiness  at  the  lower  part  of  the  belly,  with  or  without  a 
tendency  in  the  os  uteri  to  move  or  dilate,  whether  brought  on  by 
irritation  at  the  upper  part  of  the  vagina  or  os  uteri,  or  by  the  affec- 
tion of  the  neck  of  the  bladder,  &c.  may  be  often  prevented  from 
extending  farther,  by  rest,  anodynes,  and  having  immediate  re- 
course to  such  means  as  the  nature  of  the  irritation  may  require  for 
its  removal.* 

The  irritation  of  a  prolapsus  ani,  or  of  inflamed  piles,  with  or 
without  much  sanguineous  discharge,  may  excite  the  uterus  to  con- 
tract ;  and  if  the  bleeding  from  the  anus  have  been  profuse,  and  the 
woman  weakly,  it  may  destroy  the  child.  The  piles,  ought,  there- 
fore, never  to  be  neglected. 

Tapping  the  ovum,  by  which  the  uterus  collapses,  and  its  fibres 
receive  a  stimulus  to  action,  is  another  cause  by  which  abortion 
may  be  produced;  and  this  is  sometimes,  with  great  propriety, 
done  at  a  particular  period,  in  order  to  avoid  a  greater  evil.  It  is 
now  the  general  opinion,  that  contraction  will  unavoidably  follow 
the  evacuation  of  the  waters.  But  we  can  suppose  the  action  of 
gestation  to  be  in  some  cases  so  strong  as  not,  at  least  for  a  very 
considerable  time,  to  stop  in  consequence  of  this  violence,  and,  if 
it  do  not  stop,  contraction  will  not  take  place.  I  do  not,  however, 
mean  to  say,  that  all  discharges  of  watery  fluid  from  the  uterus,  not 
followed  by  abortion,  are  discharges  of  the  liquor  amnii.  On  the 
contrary,  I  know,  that  most  of  these  are  the  consequence  of  mor- 
bid action  about  the  os  uteri,  the  glands  yielding  a  serous,  instead 


*  Chronic  inflammation  of  the  heart  is  generally  attended  with  pain  at  the 
bottom  of  the  abdomen,  which  is  sometimes  mistaken  for  symptoms  of  calculus. 
7n  onp  case  abortion  seemed  to  proceed  from  this  disease  of  the  hcarU 


27B 

of  a  gelatinous  fluid,  and  this  action  «iay   continue  for  many 
months. 

In  all  these  cases,  the  woman  must  be  confined  to  bed,  and  have 
an  anodyne  every  night  at  bed-time,  for  some  time,  premising  ve- 
nesection if  the  pulse  indicate  it,  and  conjoining  gentle  laxatives. 
There  is  just  so  much  probability  of  gestation  going  on,  as  to  en- 
courage us  to  use  endeavours  to  continue  it.  In  those  instances 
where  the  discharge  is  small,  and  the  oozing  pretty  constant,  we 
conclude  that  it  is  yielded  chiefly  by  the  glands  about  the  os  uteri, 
and  may  derive  advantage  from  injecting  three  or  four  times  a  day 
a  strong  infusion  of  galls,  or  solution  of  alum.  The  woman  ought 
to  use  no  exertion,  as  the  membranes  are  apt  to  give  way. 

It  is  sometimes  necessary  to  lay  down  rules  for  the  management 
of  pregnant  women,  even  although  they  may  not  have  been  liable 
to  abortion.  These  are  to  be  drawn  from  the  remarks  already 
delivered,  and  it  is  only  requisite  to  add,  that  in  all  cases  it  is  pro- 
per to  attend  to  the  effects  of  utero-gestation,  or  the  diseases  of 
pregnancy,  which  are  to  be  mitigated,  when  severe,  by  suitable 
remedies. 

The  danger  of  abortion  is  to  be  estimated  by  considering  the 
previous  state  of  the  health,  by  attending  to  the  violence  of  the 
discharge,  and  the  difficulty  of  checking  it;  to  its  duration,  and 
the  disposition  to  expulsion  which  accompanies  it;  to  the  effects 
which  it  has  produced  in  weakening  the  system,  and  to  its  com- 
bination with  hysterical  or  spasmodic  affections.  In  general,  we 
say  that  abortion  is  not  dangerous,  yet  in  some  cases,  even  at  a 
very  early  period  of  gestation,  and  under  vigorous  treatment,  it 
does  prove  fatal  very  speedily,  either  from  loss  of  blood,  or  spasm 
in  the  stomach,  or  convulsions.  It  is  satisfactory,  however,  to 
know,  that  this  termination  is  rare,  that  these  dangerous  attendants 
are  seldom  present,  and  that  a  great  hemorrhage  may  be  sustained, 
and  yet  the  strength  soon  recover.  But  if  there  be  any  disposi- 
tion in  a  particular  organ  to  disease,  abortion  may  make  it  active, 
and  thus,  at  a  remote  period,  carry  off  the  patient.  Miscarriages, 
if  frequently  repeated,  are  also  very  apt  to  injure  the  health,  and 
break  up  the  constitution. 


279 

When  abortion  is  threatened,  the  process  is  very  apt  to  go  on 
to  completion ;  and  it  is  only  by  interposing,  before  the  expulsive 
efforts  are  begun,  that  we  can  be  successful  in  preventing  it ;  for 
whenever  the  muscular  contraction  is  universally  established, 
marked  by  regular  pains,  and  attempts  to  distend  the  cervix  and 
os  uteri,  nothing,  I  believe,  can  check  the  process.  As  this  is 
often  the  case  before  we  are  called,  or  as  in  many  instances  abor- 
tion depends  on  the  action  of  gestation  being  stopped  by  causes, 
whose  action  could  not  be  ascertained  until  the  effect  be  produced, 
we  shall  frequently  fail  in  preventing  expulsion. 

This  is  greatly  owing  to  our  not  being  called  until  abortion,  that 
is  to  sav,  the  expulsive  process  has  begun;  whereas,  had  we  been 
applied  to  upon  the  first  unusual  feeling  it  might  have  been  pre- 
vented. What  I  wish  then  particularly  to  inculcate  is,  that  no 
time  be  lost  in  giving  notice  of  any  ground  of  alarm,  and  that  the 
most  prompt  measures  be  had  recourse  to  in  the  very  beginning  ; 
for,  when  universal  uterine  contraction  has  commenced,  then  all 
that  we  can  do  is  to  conduct  the  patient  safely  through  a  confine-*- 
ment,  which  the  power  of  medicine  cannot  prevent. 

The  case  of  threatened  abortion,  in  which  we  most  frequent]}' 
succeed,  is  that  arising  from  slipping  of  the  foot,  or  from  causes 
exciting  a  temporary  over-action  of  the  vessels,  producing  a  slight 
separation;  because  here  the  hemorrhage  immediately  gives  alarm, 
and  we  are  called  before  the  action  of  gestation  be  much  affected. 
Could  we  impress  upon  our  patients  the  necessity  of  equal  atten- 
tion to  other  preceding  symptoms  and  circumstances,  we  might 
succeed  in  many  cases  where  we  fail  from  a  delay,  occasioned  by 
their  not  understanding  that  an  expulsion  can  only  be  prevented, 
by  interfering  before  that  process  begins;  for  when  sensible  signs 
of  contraction  appear,  the  mischief  has  proceeded  too  far  to  be 
checked.  Prompt  and  decided  means  used  upon  the  first  ap- 
proach of  symptoms  indicating  a  hazardous  state  of  the  uterus,  or 
on  the  earliest  appearance  of  hemorrhage,  may,  provided  the  child 
be  still  alive,  be  attended  with  success. 

In  considering  the  treatment,  I  shall,  first  of  all,  notice  the  most 
likely  method  of  preventing  abortion  in  those  who  are  subject  to 
it;  next,  the  best  means  of  checking  it,  when  it  is  immediately 


280 

threatened  j  and,  lastly,  the  proper  method  of  conducting  the  wo~ 
man  through  it,  when  it  cannot  be  avoided. 

The  means  to  be  followed  in  preventing  what  may  be  called 
habitual  miscarriage,  must  depend  on  the  cause  supposed  to  givev 
rise  to  it.  It  will,  therefore,  be  necessary  to  attend  to  the  history 
of  former  abortions ;  to  the  usual  habitudes  and  constitution  of  the 
woman  ;  and  to  her  condition  when  she  becomes  pregnant. 

In  many  instances  a  plethoric  disposition,  indicated  by  a  pretty 
full  habit,  and  copious  menstruation,  will  be  found  to  give  rise  to 
it.  In  these  cases,  we  shall  find  it  of  advantage  to  restrict  the  pa- 
tient almost  entirely  to  a  vegetable  diet,  and,  at  the  same  time, 
make  her  use  considerable  and  regular  exercise. 

The  sleep  should  be  abridged  in  quantity,  and  taken,  not  on  a^ 
bed  of  down,  but  on  a  firm  mattress,  at  the  same  time  that  we  pre- 
vent the  accumulation  of  too  much  heat  about  the  body.  The 
bowels  ought  to  be  kept  open,  or  rather  loose,  which  may  be  ef- 
fected by  drinking  Cheltenham  water,  or  taking  some  other  laxa- 
tive. We  must  not,  however,  carry  this  plan  too  far,  nor  make  a 
sudden  revolution  in  the  constitution,  as  this  may  be  productive  of 
permanent  mischief,  and  occasion  the  diseases  which  proceed  from 
a  broken  habit.  Whenever  the  strength  is  diminished,  the  appe- 
tite impaired,  or  any  other  bad  effect  is  produced,  we  have  gone 
too  great  length, 

There  is,  in  plethoric  habits,  a  weakness  of  many,  if  not  all,  of 
the  functions ;  but  this  is  not  to  be  cured  by  tonics,  but  by  conti- 
nued and  very  gradually  increased  exercise,  laxatives,  and  light 
diet,  consisting  chiefly  of  vegetables.  This  plan,  however,  must 
not  be  carried  to  an  imprudent  'ength,  nor  established  too  suddenly; 
but  regard  is  to  be  had  to  the  previous  habits.  It  is  a  general  rule, 
that  exercise  should  not  be  carried  the  length  of  fatigue,  and  that 
it  should  be  taken,  if  possible,  in  the  country ;  whilst  late  hours, 
and  many  of  the  modes  of  fashionable  life,  must  be  departed  from. 
We  may  also  derive  so  considerable  advantage  from  conjoining 
with  this  plan,  the  shower-bath  or  sea-bathing,  that  they  ought  not 
to  be  omitted.  There  is,  I  believe,  no  remedy  more  powerful  ii> 
preventing  abortion  than  the  cold  bath,  and  the  best  time  for  using 
it  is  in  the  morning.     By  means  of  this,  conjoined  with  attention 


Sfcl 

to  the  vascular  system,  and  prudent  conduct  on  the  part  of  the  pa- 
tient, I  suppose  that  nine-tenths  of  those  who  are  suhject  to  abor- 
tion, may  go  on  to  the  full  time.  If  the  shower-bath  be  employed, 
we  must  begin  with  a  small  quantity  of  water;  and,  in  some  instan- 
ces, may  at  first  add  so  much  warm  water,  as  shall  make  it  just 
feel  cold,  but  not  to  give  too  great  a  shock.  If  the  cold  bath  cause 
headach,  this  may  often  be  prevented  by  premising  one  or  two 
doses  of  physic. 

After  conception,  the  exercise  must  be  taken  with  circumspec- 
tion :  but  the  diet  must  still  be  sparing,  and  the  use  of  the  cold 
bath  continued.  If  the  pulse  be  at  any  time  full,  or  inclined  to 
throb,  or  if  the  patient  be  of  a  vigorous  habit,  a  little  blood  should 
be  taken  away  at  a  very  early  period.  In  some  cases,  where  the 
action  is  great,  we  must  bleed  almost  immediately  after  the  sup- 
pression of  the  menses.  It  is  not  necessary  to  bleed  copiously ;  it 
is  much  better  to  take  away  only  a  few  ounces,  and  repeat  the  evacu/- 
ation  when  required,  and  we  should  manage  so  as  to  avoid  fainting. 
The  cold  bath  should  be  conjoined,  and  we  may  derive  advantage 
by  using  the  digitalis,*  so  as  slightly  to  affect  the  pulse,  keeping  it 
at  or  below  its  natural  frequency,  and  to  diminish  its  throbbing. 
But  it  is  not  requisite  to  be  given  to  the  degree  employed  in  some 
other  complaints;  and  if  it  be  pushed  to  an  imprudent  length,  the 
child  may  suffer.  Half  a  grain  may  be  given,  twice  or  thrice  a-day. 
It  may  be  continued  for  two  days,  and  then  omitted  for  a  day  ;  and. 
in  this  way  it  may  be  continued  till  the  danger  is  past.  In  those- 
cases  where  the  digitalis  produces  feebleness,  it  is  evidently  im- 
proper to  continue  it  regularly.  Indeed,  when  this  effect  take$ 
place,  its  further  exhibition  is  unnecessary.  It  is  also  improper 
where  it  acts  powerfully  on  the  kidneys.  By  attending  to  these 
cautions,  it  may,  in  some  cases  requiring  it,  be  continued  with  oc- 
casional omissions  of  a  day  or  two,  even  for  some  weeks,  but  it  is 
very  seldom  necessary  to  persist  in  it  above  a  fortnight  at  most. 


*  The  acetite  of  lead  has  been  recommended  by  the  ingenious  and  justly  ce- 
lebrated Dr.  Uush  of  Philadelphia,  in  doses  of  from  one  to  three  grains,  given 
three  times  a-day.  Of  this  practice  I  cannot  speak  from  my  own  experience ;  byX 
Dr.  Rush  informs  me  that  in  his  hands  it  has  bee,n  attended  with  gre^t  success 

37 


282 

Injecting  cold  water  into  the  vagina,  twice  or  thrice  a-day,  has 
often  a  good  effect,  at  the  same  time  that  we  continue  the  shower- 
bath  every  morning.  When  there  is  much  aching  pain  in  the  back, 
it  is  of  service  to  apply  cloths  to  it,  dipped  in  cold  water,  or  gently 
to  dash  cold  water  on  it;  or  employ  a  partial  shower-bath,  by 
means  of  a  small  watering-can. 

In  this,  as  in  all  other  cases  of  habitual  abortion,  we  must  ad- 
vise, that  impregnation  shall  not  take  place  until  we  have  corrected 
the  system ;  and  after  the  woman  has  conceived,  it  is  requisite  that 
she  live  absque  marito,  at  least  until  gestation  be  far  advanced.  I 
need  hardly  add,  that  when  consulted  respecting  habitual  abortion, 
the  strictest  prudence  is  required  on  our  part,  and  that  the  situation 
of  the  patient,  and  many  of  our  advices,  should  be  concealed  from 
the  most  intimate  friends  of  the  patient. 

In  other  cases,  we  find  that  the  cause  of  abortion  is  connected 
with  sparing  menstruation.  This  is  often  the  case  with  women 
whose  appearance  indicates  good  health,  and  who  have  a  robust 
look.  This  is  not  often  to  be  rectified  by  medicine,  but  it  may 
by  regimen,  &c.  Here,  as  in  the  former  case,  we  find  it  useful  to 
make  the  greatest  part  of  the  diet  consist  of  vegetables;  but  it  is 
not  necessary  to  restrict  the  quantity. 

When,  on  the  other  hand,  the  patient  has  a  weakly  delicate  ap- 
pearance, it  will  be  proper  to  give  a  greater  proportion  of  animal 
food,  and  two  or  three  glasses  of  wine,  in  the  afternoon,  with  some 
bitter  laxative,  twice  a-day,  so  as  to  strengthen  the  stomach,  and 
at  the  same  time  keep  the  bowels  open. 

We  also  derive  in  both  cases,  advantage  from  the  daily  use  of 
the  warm  bath,  made  of  a  pleasant  temperature ;  but  this  is  to  be 
omitted  after  conception  ;  at  least  for  the  first  ten  or  twelve  weeks; 
after  which,  if  there  be  symptoms  of  irritation,  or  feeling  of  tension 
about  the  belly,  or  pain  about  the  groins,  or  pubis,  it  may  be  em- 
ployed, and  is  both  safe  and  advantageous.  But  when  the  patient 
is  of  a  phlegmatic  habit,  or  subject  to  profuse  fluor  albus,  it  is  not 
indicated,  and  sometimes  is  pernicious.  The  internal  use  of  the 
Bath  waters,  previous  to  conception,  is  often  of  service ;  or  where 
the  circumstances  of  the  patient  will  not  permit  this,  we  may  desire 
her  to  drink,  morning  and  evening,  a  pint  of  tepid  water,  containing 


283 

half  a  drachm  of  sweet  spirit  of  nitre.  Throwing  up  into  the  vagina, 
tepid  salt-water  twice  or  thrice  a-day,  seems  also  to  have  a  good 
effect. 

I  have  already  mentioned,  that  abortion  is  sometimes  the  con- 
sequence of  too  firm  action,  the  different  organs  refusing  to  yield 
to  the  uterus,  which  is  thus  prevented  from  enjoying  the  due  quan- 
tity of  energy  and  action.  These  women  have  none  of  the  dis- 
eases of  pregnancy,  or  they  have  them  in  a  slight  degree.  They 
have  good  health  at  all  times,  hut  they  either  miscarry,  or  have  la- 
tour  in  the  seventh  or  eighth  month,  the  child  being  dead ;  or  if 
they  go  to  the  full  time,  I  have  often  observed  the  child  to  be  sickly, 
and  of  a  constitution  unfitting  it  for  living.  Blood-letting  is  useful 
by  making  the  organs  more  irritable.  The  tepid  bath  is  in  gene- 
ral of  advantage,  and  may  be  employed  every  second  evening  for 
some  time. 

There  is  another  case  in  which  all  the  functions  are  healthy  and 
firm,  except  the  circulation,  which  is  accelerated  by  the  uterine  ir- 
ritation. This  is  more  or  less  the  case  in  every  pregnancy ;  but 
here  it  is  a  prominent  symptom.  The  woman  is  very  restless,  and 
even  feverish,  and  apt  to  miscarry,  especially  if  she  be  of  a  full 
habit.  Immediate  relief  is  given  by  venesection;  and  afterwards 
we  may,  for  some  time,  give  every  night  half  a  grain  or  a  grain  of 
digitalis,  with  two  grains  of  the  extract  of  hyoscyamus. 

When,  on  the  contrary,  abortion  arises  from  too  easy  yielding 
of  some  organ,  we  must  keep  down  uterine  action,  by  avoiding  ve- 
nery,  and  injecting  cold  water  often  into  the  vagina,  or  pouring  cold 
water  every  morning  from  a  watering-can,  upon  the  loins  and  ilia; 
at  the  same  time  we  must  attend  to  the  organ  sympathizing  with 
the  uterus. 

Sometimes  it  is  the  stomach  which  is  irritable,  and  the  person  is 
often  very  sick,  takes  little  food,  and  digests  ill.  A  small  blister, 
or  leeches,  applied  to  the  pit  of  the  stomach  often  relieve  this ;  a 
little  of  the  compound  tincture  of  bark,  taken  three  or  four  times 
a-day,  is  serviceable  ;  or  a  few  drops  of  the  tincture  of  miniated 
iron,  in  a  tumbler  glassful  of  aerated  water.  At  other  times  the 
bowels  yield,  and  the  patient  is  obstinately  costive.     This  is  cured 


284 

by  aloetic  pills,  or  manna,  with  the  tartarite  of  potash.  When  the 
muscular  system  yields,  producing  a  feeling  of  languor  and  gene- 
ral weakness,  the  use  of  the  cold  bath,  with  a  grain  of  opium  at 
bed-time,  will  be  of  most  service. 

It  is  evident,  that  it  is  only  by  attending  minutely  to  the  history 
of  former  miscarriages,  that  we  can  detect  these  causes  ;  and  we 
shall  generally  find,  that  in  each  individual  case,  it  is  the  same 
organ  in  every  pregnancy  which  has  yielded  or  suffered.  Previ- 
ous to  future  conception,  we  may  with  propriety,  endeavour  to 
render  it  less  easily  affected. 

General  weakness  is  another  condition  giving  rise  to  abortion  ; 
^and  upon  this  I  have  already  made  some  remarks.  I  have  here 
only  to  add,  that  the  use  of  the  cold  bath,  the  exhibition  of  the  Pe- 
ruvian bark,  and  wearing  flannel  next  the  skin,  constitute  the  most 
successful  practice. 

Syphilis  is  likewise  a  cause  of  abortion.  When  it  occurs  in  the 
mother,  it  often  unfits  the  uterus  for  going  on  with  its  actions. 
At  other  times,  more  especially  when  the  father  labours  under 
venereal  hectic,  or  has  not  been  completely  cured,  the  child 
is  evidently  affected,  and  often  dies  before  the  process  of  gestation 
can  be  completed.  In  these  cases,  a  course  of  mercury  alone  can 
effect  a  cure.  But  we  are  not  to  suppose  that  every  child,  born 
without  the  cuticle  in  an  early  stage  of  pregnancy,  has  suffered 
from  this  cause  ;  on  the  contrary,  as  some  of  these  instances  de- 
pend on  causes  already  mentioned,  and  which  cannot  be  cured  by 
mercury,  1  wish  to  caution  the  student  against  too  hastily  conclud- 
ing that  one  of  the  parents  has  been  diseased,  because  the  child  is 
born  dead  or  putrid  at  an  early  period.  It  is  not  always  easy  to 
form  a  correct  judgment ;  but  we  may  be  assisted  by  finding  that 
the  other  causes  which  I  have  mentioned  are  absent ;  that  we  have 
appearances  of  ulceration  on  the  child,  and  that  there  are  some 
suspicious  circumstances  in  the  former  history  and  present  health 
of  the  parents.  A  child  may  be  born  dead,  and  even  putrid,  not 
only  in  consequence  of  syphilis,  but  also  of  some  malformation  of 
the  foetus  itself,  or  of  its  appendages  ;  or  of  a  general  imperfection 
of  the  ovum,  usually  combined  with  an  increased  quantity  of  li- 
quor amnii ;  or  of  original  debility  of  constitution,  unfitting  the 


285 

child  for  coming  to  maturity  ;  or  of  fatal  derangement  of  structure 
or  action,  taking  place  in  utcro,  from  causes  not  very  obvious  ;  or 
from  weakness  or  imperfect  action  of  the  uterus  itself,  or  such  a 
condition  of  it  as  sometimes  produces  epilepsy  ;  or  it  is  in  certain 
cases  occasioned  by  a  convulsion.  Most  of  these  causes  are  not 
under  our  control;  and  indeed,  with  the  exception  of  the  case  of 
syphilis,  we  can  only  propose  to  prevent  the  death  of  the  child, 
by  the  use  of  such  general  means  as  invigorate  the  constitution  of 
the  parent,  or  as  obviate  palpable  predisposing  causes  of  injury  to 
the  uterine  functions. 

Advancement  in  life,  before  marriage,  is  another  cause  of  fre- 
quent abortion,  the  uterus  being  then  somewhat  imperfect  in  its 
•action.  In  general  we  cannot  do  much  in  this  case,  except  avoid- 
ing carefully  the  exciting  causes  of  abortion  ;  and  by  attending 
minutely  to  the  condition  of  other  organs,  during  menstruation  or 
pregnancy,  we  may,  from  the  principles  formerly  laid  down,  do 
some  good. 

It  is  satisfactory  to  know,  that  although  we  may  fail  once  or 
twice,  yet,  by  great  care,  the  uterus  comes  at  last  to  act  more  per- 
fectly, and  the  woman  bears  children  at  the  full  time. 

After  these  observations,  it  is  only  necessary  to  add,  that  in  every 
instance  of  habitual  abortion,  whatever  the  condition  may  be  which 
gives  rise  to  it,  we  find  it  is  essential  that  the  greatest  attention  be 
paid  to  the  avoiding  of  the  more  evident  and  immediate  exciting 
causes  of  miscarriage,  such  as  fatigue,  dancing,  Sic.  In  some  cases, 
it  may  even  be  necessary  to  confine  the  patient  to  her  room,  until 
the  period  at  which  she  usually  miscarries  is  past. 

When  abortion  is  threatened,  we  come  to  consider  whether,  and 
by  what  means,  it  can  be  stopped.  I  have  already  stated  my  opinion, 
that  when  the  action  of  gestation  ceases,  it  cannot  be  renewed,  and 
that  general  contraction  of  the  uterine  fibres  is  a  criterion  of  this 
cessation. 

Still,  as  some  of  the  means  which  may  be  supposed  useful  in 
preventing  a  threatened  abortion,  are  also  useful  in  moderating  the 
symptoms  attending  its  progress,  we  may  properly  have  recourse 
to  them.  Some  causes  giving  rise  to  abortion,  do  not  immediately 
produce  it,  but  give  warning  of  their  operation,  producing  uneasi* 


286 

ness  in  the  vicinity  of  the  uterus,  before  the  action  of  that  organ  be 
materially  affected.  The  detraction  of  a  little  blood  at  this  time,  if 
the  pulse  be  in  any  measure  full  or  frequent,  or  if  the  patient  be 
not  of  a  habit  forbidding  evacuations,  and  the  subsequent  exhibition 
of  an  anodyne  clyster,  or  a  full  dose  of  opium,*  together  with  a  state 
of  absolute  rest  in  a  recumbent  posture  for  some  days,  will  often 
be  sufficient  to  prevent  further  mischief,  and  constitute  the  most 
efficacious  practice.  The  patient  should  be  strictly  confined  to  bed, 
sleeping  with  few  bed-clothes,  and  without  a  fire  in  her  apartment. 
Indeed  the  very  first  thing  to  be  done  on  entering  the  room,  is  to 
order  the  patient  to  bed.  The  diet  should,  in  general,  be  low, 
consisting  of  dry  toast,  biscuit,  and  fruit;  and  much  fluid,  especially 
warm  fluid,  should  be  avoided. 

This  is  the  time  at  which  we  can  interfere  with  the  most  certain 
prospect  of  success ;  and  the  greatest  attention  should  be  paid  to 
the  state  of  the  rest  of  the  system;  removing  uneasiness,  wherever 
it  is  present,  and  preventing  any  organ  from  continuing  in  a  state  of 
undue  action.  It  is  difficult  to  persuade  the  patient  to  comply  with 
that  strict  attention  which  is  necessary  at  this  period ;  but  being 
persuaded  that  if  this  period  be  allowed  to  pass  over  with  neglect, 
and  contraction  begins,  nothing  can  afterwards  prevent  abortion,  I 
wish  particularly  to  impress  the  mind  of  the  student  with  a  due 
sense  of  its  importance;  and  I  must  add,  that  as  after  every  appear- 
ance of  morbid  uterine  action  is  over,  the  slightest  cause  will  re- 
new our  alarm,  it  is  necessary  great  attention  be  paid  for  some  time 
to  the  patient. 

Often,  instead  of  an  uneasy  feeling  about  the  loins,  or  lower  belly, 
we  have,  before  the  action  of  gestation  stops,  a  discharge  of  blood, 
generally  in  a  moderate,  sometimes  in  a  trifling  degree.  This  is 
more  especially  the  case  when  abortion  is  threatened,  owing  to  an 
external  cause ;  and,  if  immediately  checked,  we  may  prevent  con- 
traction from  beginning. 

Even  in  those  cases  where  we  do  not  expect  to  ward  off  expul- 
sion, it  is  useful  to  prevent,  as  far  as  we  can,  the  loss  of  blood ;  for 

*  Opiates  arc  of  signal  benefit  in  this  situation,  and  should  seldom  be  omitted 
after  venesection. 


237 

as  I  eannot  see  that  the  hemorrhage  is  necessary  for  its  accomplish- 
ment, although  it  always  attend  it,  I  conclude  that  our  attempts 
to  prevent  bleeding  can  never  do  harm  ;  if  they  succeed  in  check- 
ing abortion,  we  gain  our  object ;  if  they  fail,  they  do  not  increase, 
but  diminish  the  danger. 

It  should  be  carefully  remembered,  that  the  more  we  can  save 
blood,  the  more  do  we  serve  our  patient.  As  the  means  for  check- 
ing the  discharge  will  be  immediately  pointed  out,  it  is  unnecessary 
here  to  enter  into  any  detail. 

Sometimes  the  vessels  about  the  cervix  and  os  uteri  yield,  post 
eoitum,  a  little  blood ;  and  this  may  occur  either  in  those  who  have 
the  uterus  in  a  high  state  of  activity,  or  more  frequently  where  it  is 
feeble  in  its  functions.  The  same  discharge  may  sometimes  appear 
in  rather  greater  quantity  after  impregnation,  passing  perhaps  for 
the  menses,  and  making  the  woman  uncertain  as  to  her  situation ; 
but  it  is  generally,  though  not  always,  irregular  in  its  appearance, 
and  seldom  returns  above  once  or  twice.  In  some  instances,  how- 
ever, it  becomes  greater  and  more  frequent  in  proportion  as  the 
vessels  increase  in  size.  It  is  now  apt  to  pass  for  monorrhagia. 
If  it  be  allowed  to  continue,  it  tends  to  injure  the  action  of  the 
uterus,  and  produces  expulsion,  which  sometimes  is  the  first  thing 
which  shows  the  woman  her  situation.  The  discharge  is  best  ma- 
naged by  rest,  the  frequent  injection  of  saturated  solution  of  the 
sulphate  of  alumine,  or  decoction  of  oak  bark,  and  the  internal  use 
of  tincture  of  kino. 

When  a  slight  discharge  takes  place,  in  consequence  of  a  slip  of 
the  foot,  or  some  other  external  cause,  we  may  also  derive  advan- 
tage from  the  use  of  the  injection;  but  if  the  discharge  be  con- 
siderable, it  will  often  fail.  It  is  better,  in  such  a  case,  to  trust  to 
the  formation  of  a  coagulum. 

When  in  a  plethoric  habit  abortion  is  threatened,  from  a  fright. 
or  mental  agitation,  we  have  often  palpitation,  rapidity  of  the 
pulse,  headach,  flushed  face,  and  pain  about  the  back  or  pubis  : 
blood-letting  relieves  immediately  the  uneasiness  in  the  head,  and 
often  the  pain  in  the  back  ;  afterwards,  the  patient  in  to  be  kepi 
cool  and  quiet,  and  an  anodyne  administered, 


288 

In  those  cases,  where  regular  uterine  pain  precedes  or  acconi-= 
panies  the  discharge,  expulsion  cannot  be  prevented ;  but  when 
the  discharge  precedes  the  pain,  it  sometimes  may;  nay,  if 
the  child  be  still  alive,  it  frequently  may.  Rest  is  absolutely 
necessary,  if  we  wish  the  person  to  go  to  the  full  time  :  and  it  is 
occasionally  necessary  to  confine  her  to  bed  for  several  weeks, 
prescribe  the  prudent  and  occasional  use  of  digitalis,*  and  give 
an  anodyne  at  bed-time,  taking  care  also  to  keep  the  bowels 
in  a  proper  state  by  gentle  medicine.  Blood  ought  also,  unless 
the  pulse  and  habit  of  the  patient  forbid  it,  to  be  detracted. 
A  table  spoonful  of  tincture  of  kino  may  be  given  three  times 
daily.  Styptic  injections  into  the  vagina,  two  or  three  times  a-day, 
are  of  great  benefit. 

This  is  a  very  critical  situation :  much  depends  on  the  vigour 
and  promptitude  of  our  practice  ;  and  much,  very  much,  upon  the 
prudence  of  the  patient.  It  is  teazing  to  find,  that  sometimes  after 
all  our  care  and  exertions,  one  rash  act  destroys  in  a  single  day 
the  effect  of  the  whole. 

When  we  cannot  prevent  abortion,  the  next  thing  is  to  conduct 
the  patient  safely  through  the  process,  by  lessening  the  effects  of 
separation  or  detachment  of  the  ovum,  and  accelerating  the  con- 
traction. The  first  point  which  naturally  claims  our  attention  is 
the  hemorrhage.  Many  practitioners,  upon  a  general  principle, 
bleed  in  order  to  check  this,  and  prevent  miscarriage ;  but  mis- 
carriage cannot  be  prevented,  if  the  uterine  contraction  have  uni- 
versally commenced;  and  the  discharge  cannot  be  prudently 
moderated  by  venesection,  unless  there  be  undue  or  strong  action 
in  the  vessels,  or  much  blood  in  the  system ;  and  if  so,  a  vein  may 
be  opened  with  advantage.     This  is  not  always  the  case,  and 

*  I  have  in  a  preceding  note,  advised  some  caution  in  the  use  of  digitalis  hx 
uterine  noodings.  I  would  here,  also,  recommend  the  same  degree  of  circum- 
spection. When  given  in  sufficient  quantity  to  make  any  very  sensible  impres- 
sion on  the  system  generally,  it  seems,  in  a  very  peculiar  manner,  to  relax  and 
debilitate  the  vessels  of  the  uterus,  disposing  them,  thereby,  to  passive  hemor- 
rhage. When,  however,  it  is  administered  with  proper  restrictions,  1  have  no. 
doubt  it  may  prove  both  a  safe  and  a  useful  medicine.  But  still,!  would  greatV 
prefer  to  bleed  in  the  above  cases.    C« 


289 

therefore,  unless  the  vessels  be  at  or  above  the  natural  force  or 
strength  of  action,  the  lancet  is  not  at  this  stage  necessary.  The 
fulness  and  strength  of  the  pulse  are  lost  much  sooner  in  abortion 
than  can  be  explained,  by  the  mere  loss  of  blood.  This  depends 
on  an  affection  of  the  stomach,  which  has  much  influence  on  the 
pulse ;  and  the  proper  time  for  bleeding  is  before  this  has  taken 
place.  When  abortion  has  made  so  much  progress  before  we  are 
called,  as  to  have  rendered  the  pulse  small  and  feeble;  or  when 
this  is  the  case  from  the  first,  bleeding  evidently  can  do  no  good. 
Instead  of  this,  we  may  rather  use  the  digitalis,  but  in  ordinary 
cases,  where  the  contraction  is  brisk,  and  the  process  quick,  it  is 
not  at  this  stage  absolutely  necessary  ;  and  I  shall  afterwards  men- 
tion that,  when  the  stomachic  affection  is  urgent,  and  the  pulse 
much  affected  by  it,  the  use  of  this  medicine  is  improper.  When, 
however,  the  case  is  tedious,  and  the  discharge  long  continued,  at 
the  same  time  that  the  sickness  is  not  considerable,  the  digitalis 
will  be  of  essential  service,  and  it  may  be  very  properly  com- 
bined with  the  sulphuric  acid.  Nauseating  doses  of  emetic  medi- 
cines act  in  the  same  way  with  the  digitalis,  but  are  much  less 
effectual,  and  more  disagreeable,  as  well  as  uncertain  in  then- 
operation.  Internal  astringents  have  been  proposed,  but  they  have 
no  effect  in  copious  hemorrhage,  unless  they  excite  sickness, 
which  is  a  different  operation  from  that  which  is  expected  from 
them.  They  are  more  useful  in  protracted,  but  moderate  hemor- 
rhage. 

The  application  of  cloths,  dipped  in  cold  water,  to  the  back  and 
external  parts  ought  always  to  be  had  recourse  to.  If  the  digitalis 
have  been  exhibited,  it  assists  that  medicine  in  moderating  the 
circulation.  Even  when  trusted  to  alone,  it  lessens  the  action  of 
the  sanguiferous  system,  particularly  of  the  uterine  vessels.  The 
introduction  of  a  small  piece  of  smooth  ice  into  the  vagina  has 
been  recommended,  and  has  often  a  very  speedy  effect  in  retard- 
ing the  hemorrhage,  whilst  it  never,  if  properly  managed,  does  any 
harm.  A  small  snow-ball,  wrapped  in  a  bit  of  linen,  will  have 
the  same  effect;  but  neither  of  these  must  be  continued  so  long  as 
to  produce  pain,  or  much  and  prolonged  shivering.     The  heat  of 

38 


290 

the  surface  is  also  to  be  moderated,  by  having  few  bed-clothes, 
and  a  free  circulation  of  cool  air. 

But  the  most  effectual  local  method  of  stopping  the  hemor- 
rhage is  by  plugging  the  vagina.  This  is  best  done  by  taking  a 
pretty  large  piece  of  soft  cloth,  and  dipping  it  in  oil,  and  then 
wringing  it  gently.  It  is  to  be  introduced  with  the  finger,  portion 
after  portion,  until  the  lower  part  of  the  vagina  be  well  filled.  The 
remainder  is  then  to  be  pressed  firmly  on  the  orifice.  This  acts 
by  giving  the  effused  blood  time  to  coagulate.  It  gives  no  pain ; 
it  produces  no  irritation ;  and  those  who  condemn  it,  surely  must 
either  not  have  tried  it  or  have  misapplied  it.  If  we  believe  that 
abortion  requires  for  its  completion  a  continued  flow  of  blood,  we 
ought  not,  in  those  cases  where  the  process  must  go  on,  to  have 
recourse  to  cold,  or  other  means  of  restraining  hemorrhage.  If 
we  do  not  believe  this,  then  surely  the  most  effectual  method  of 
moderating  it  is  the  best.  Plugging  can  never  retard  the  process, 
nor  prevent  the  expulsion  of  the  ovum ;  for  when  the  uterus  con- 
tracts, it  sends  it  down  into  the  clotted  blood  in  the  upper  part  of 
the  vagina,  and  the  flooding  ceases. 

Faintness  operates  also  in  many  cases,  by  allowing  coagula  to 
form,  in  consequence  of  the  blood  flowing  more  slowly;  and  when 
the  faintness  goes  off,  the  coagula  still  restrain  the  hemorrhage  in 
the  same  way  as  when  the  plug  has  been  used.  This  naturally 
points  out  the  advantage  of  using  the  plug,  together  with  the  digi- 
talis, as  we  thus  produce  coagulation  at  the  mouth  of  the  vessels, 
and  also  diminish  the  vascular  action.  It  will  likewise  show  the 
impropriety  of  using  injections  at  this  time;  for  by  washing  out 
the  coagula,  we  do  more  harm  than  can  be  compensated  by  any 
astringent  effect  produced  on  the  vessels. 

The  principal  means,  then,  which  we  employ  for  restraining  the 
hemorrhage,  are  bleeding,  if  the  pulse  be  full  and  sharp;  if  not, 
we  trust  to  the  digitalis,  combined  with  sulphuric  acid,  except  in 
those  cases  already  specified,  as  forbidding  its  use,  in  which  we 
may  substitute  kino :  to  stuffing  the  vagina  :  to  the  application  of 
cold  to  the  external  parts,  keeping  the  heat  of  the  body  in  general 
at  a  low  temperature;  and  enforcing  a  state  of  absolute  rest,  which 


291 

must  be  continued  during  the  whole  process,  however  long  it  may. 
in  some  cases,  be.  The  drink  should  be  cold,  and  the  food,  if  the 
patient  desire  any,  light,  and  taken  in  small  portions. 

Opiates  have  been  advised,  in  order  to  abate  the  discharge,  and 
are,  by  many,  used  in  every  case  of  abortion,  and  in  every  stage. 
But,  as  we  cannot  finish  the  process  without  muscular  contraction, 
and,  as  they  tend  to  suspend  that,  I  do  not  see  that  their  constant 
exhibition  can  be  defended  on  rational  principles.  If  given  in 
small  quantity,  they  do  no  good  in  the  present  point  of  view ;  if 
in  larger  doses,  they  only  postpone  the  evil,  for  they  cannot  check 
abortion  after  contraction  has  begun.  But  I  will  not  argue  against 
the  use  of  opiates  from  their  abuse.  They  are  very  useful  in  cases 
of  threatened  abortion,  more  especially  in  accidental  separation  of 
the  membranes  and  consequent  discharge.  They  do  not  directly 
preserve  the  action  of  gestation,  but  they  prevent  the  tendency  to 
muscular  contraction,  and  thus  do  good.  In  weakly  or  emaciated 
habits,  opiates  alone,  if  given  upon  the  first  appearance  of  mis- 
chief, are  often  sufficient  to  prevent  abortion ;  and,  in  opposite 
conditions,  when  preceded  by  venesection,  they  are  of  great  ser- 
vice. Opiates  are  likewise  useful  for  allaying  those  sympathetic 
pains  about  the  bowels,  and  many  of  the  nervous  affections  which 
precede  or  accompany  abortion.  They  are  also  of  much  benefit 
in  cases  where  we  have  considerable  and  protracted  discharge, 
with  trifling  pains,  as  the  uterus  is  not  contracting  sufficiently  to 
expel  the  ovum,  but  merely  to  separate  vessels,  and  excite  hemor- 
rhage. By  suspending  for  a  time  its  action,  it  returns  afterwards 
with  more  vigour  and  perfection,  and  finishes  the  process.  But 
when  the  process  is  going  on  regularly,  opiates  will  only  tend  to 
interfere  with  it,  and  prolong  the  complaint. 

It  was  at  one  time,  a  very  frequent  practice  to  endeavour,  with 
the  finger  or  small  forceps,  to  extract  the  foetus  and  placenta,  in  or- 
der to  stop  the  discharge.  Puzos  strongly  opposed  this  practice, 
and  it  is  now  very  properly  given  up  as  a  general  rule.  I  do  not 
wish,  however,  to  be  understood  as  altogether  forbidding  manual 
assistance;  but  I  am  much  inclined  to  consider  it  a  useful  precept, 
not  to  be  hasty  in  attempting  to  extract  the  ovum.  If  the  discharge 
be  protracted,  and  the  membranes  entire,  we  may,  if  the  situation 


292 

of  the  patient  require  it,  sometimes  accelerate  expulsion,  by  eva- 
cuating the  liquor  amnii.  But  if  the  pregnancy  be  not  advanced 
beyond  the  fourth  month,  it  will  be  better  to  trust  to  smart  clys- 
ters, and  restrain  the  hemorrhage  by  means  of  the  plug.  We  thus 
have  a  greater  likelihood  of  getting  all  the  ovum  off  at  once,  and 
may  excite  the  action  by  gently  dilating  the  os  uteri,  and  moving 
the  finger  round  it.  If  the  membranes  have  given  way,  and  the 
foetus  be  still  retained,  we  may,  by  insinuating  a  finger  within  the 
uterus  cautiously,  hook  it  out ;  or,  in  many  cases,  it  will  be  found 
partly  expelled  through  the  os  uteri,  and  may  easily  be  helped 
away.  But  the  most  tedious  and  troublesome  case  generally  is 
that  in  which  the  foetus  has  been  expelled,  but  the  secundines  are 
still  retained,  under  one  of  two  circumstances,  namely,  either  they 
are  only  partially  detached,  and  still  adherent  to  a  certain  extent, 
or  there  is  a  circular  and  spasmodic  contraction  of  the  uterine  fibres 
around  a  portion  of  them  j  a  state  which  may  occur  even  before 
the  foetus  itself  be  expelled.  Now,  we  never  can  consider  the  pa- 
tient as  secure  from  hemorrhage  until  these  be  thrown  off,  and 
therefore  she  must  be  carefully  watched,  especially  when  gestation 
is  considerably  advanced.  In  a  great  majority  of  instances,  the 
uterus,  within  a  few  hours,  contracts  and  expels  them.  But  in 
some  cases,  the  hemorrhage  does  become  profuse,  and  there  is 
little  disposition  to  throw  them  off.  By  stuffing  the  vagina,  we 
shall  often  find  that  the  discharge  is  safely  stopped,  and  the  womb 
excited  to  act  in  a  short  time ;  or  a  warm  saline  clyster  is  to  be 
given,  of  such  strength  as  shall  briskly  stimulate  the  rectum,  and 
excite  sympathetically  the  uterus.  But  if  we  be  disappointed,  or 
the  symptoms  urgent,  the  finger  must  be  introduced  within  the 
uterus,*  and  the  remains  of  the  ovum  slowly  detached  by  very 
gentle  motion;  and  we  must  be  very  careful  not  to  endeavour  to 
pull  away  the  secundines  until  they  be  fully  loosened,  for  we  thus 
leave  part  behind,  which  sometimes  gives  a  great  deal  of  trouble; 
and  further,  if  we  rashly  endeavour  to  extract,  we  irritate  the  ute- 
rus, and  are  apt  to  excite  inflammation,  or  a  train  of  hysterical, 

*  In  some  instances  the  half  of  the  secundines  will  be  found  in  the  vagina,  and 
the  other  half  still  in  the  uterus.  In  this  case,  all  that  is  necessary  is  gently  to 
bring  them  out. 


293 

and  sometimes  fatal  symptoms.  It  is  these  two  circumstances 
which  make  me  cautious  in  advising  manual  assistance;  and,  for- 
tunately, the  proportion  of  cases  requiring  it  is  not  great  in  abor- 
tion at  an  early  period.  When  there  is  retention  of  the  secundines, 
with  repeated  or  continued  discharge,  and  frequent  but  useless 
pains,  with  feeling  of  sickness  or  sinking,  we  may  suspect  that  part 
of  the  uterus  is  contracting  spasmodically  round  the  upper  portion 
of  the  placenta,  whilst  all  the  rest  is  detached.  This  state  of  the 
womb,  known  under  the  name  of  the  hour-glass  contraction,  is  fre- 
quent after  delivery  at  the  full  time ;  but  it  is  perhaps  scarcely  less 
so  after  abortion,  and  may  be  met  with  even  at  a  very  early  pe- 
riod, and  most  probably  is  the  cause  of  every  obstinate,  and  espe- 
cially every  fatal,  case.  If  a  smart  clyster  do  not  excite  re- 
gular and  efficient  contraction,  it  is  necessary  to  introduce  the 
hand  into  the  vagina,  and  with  one  or  more  fingers  remove  the 
secundines,  and  excite  the  womb  to  proper  action.  The  part  of 
the  placenta  retained  in  the  upper  division  by  the  constriction,  is 
sometimes  not  larger  than  a  walnut,  although  the  patient  be  three 
or  four  months  pregnant. 

When  part  of  the  ovum  is  left,  or  the  whole  of  the  secundines 
are  retained,  for  a  considerable  time,  we  have  another  danger  be- 
sides hemorrhage ;  for,  within  a  few  days,  putrefaction  comes  on, 
and  much  irritation  is  given  to  the  system,  until  the  foetid  sub- 
stance be  expelled.  Sometimes,  if  gestation  have  not  been  far  ad- 
vanced, or  the  piece  which  is  left  be  not  very  large,  it  continues 
to  come  away  in  small  bits  for  many  months  ;  and  during  the 
whole  time,  the  woman  is  languid,  hysterical,  and  subject  to  irre- 
gularities of  the  menstrua,  very  often  to  obstruction.  But  more 
frequently  the  symptoms  are  very  acute  ;  we  have  loss  of  appetite, 
prostration  of  strength,  tumid  or  tender  belly,  frequent,  small,  and 
sharp  pulse,  hot  and  parched  state  of  the  skin  of  the  hands  and 
feet,  nocturnal  sweats,  and  various  hysterical  symptoms.  The 
discharge  from  the  vagina  is  abominably  foetid,  and  hemorrhage 
sometimes  occurs  to  a  violent  degree.  The  treatment  of  this  will 
hereafter  be  pointed  out. 

From  these  observations  we  may  see,  upon  the  one  hand*  the- 


294 

impropriety  of  allowing  the  secundines  to  remain  too  long  in  the 
uterus;  and,  on  the  other,  the  danger  of  making  rash  or  unnecessa- 
ry attempts  to  extract,  by  which  we  irritate  the  uterus,  and  tear  the 
placenta,  which  is  almost  always  productive  of  troublesome  conse- 
quences. The  mechanical  removal  of  the  placenta  is  effected  with 
least  trouble  and  smallest  irritation,  in  those  cases  in  which  it  is 
most  required,  namely,  where  it  is  entirely  or  nearly  detached,  but 
still  retained  by  a  spasmodic  contraction  round  the  upper  part, 
whilst  in  those  where  there  is  adhesion,  there  is  generally  less  oc- 
casion to  interfere,  in  the  way  of  extraction,  on  account  of  the  se- 
verity of  the  hemorrhage.  I  now  return  to  the  consideration  of 
the  usual  progress  of  abortion.  The  stomach  very  soon  suffers, 
and  becomes  debilitated,  producing  a  general  languor  and  feeble- 
ness, with  a  disposition  to  faint,  which  seems  in  abortion,  to  de- 
pend more  upon  this  cause  than  directly  upon  loss  of  blood.  In- 
deed, the  hemorrhage  produces  both  slighter  and  less  permanent 
effects  in  abortion  than  at  the  full  time,  although  less  blood  may 
have  been  lost  in  the  latter,  than  in  the  former  case,  for  the  ves- 
sels are  smallar  and  the  discharge  is  not  so  sudden.  There  is  still 
another  cause  for  this  ;  namely,  that  the  action  of  the  uterus  is  less 
in  the  early  than  in  the  late  months.  Now,  we  know  that  the  ef- 
fect of  hemorrhage  from  any  organ  is,  ceteris  paribus,  in  propor- 
tion to  its  degree  of  action.  Hence  the  discharge  is  less  dangerous 
than  at  the  full  time,  and  still  less  in  menorrhagia  than  in  abortion. 
The  effect  of  abortion  on  the  stomach  seems  to  be  in  propor- 
tion to  the  period  at  which  it  takes  place,  being  greater  when  it 
occurs  before  the  fourth  month  than  after  it.  The  effect,  though 
distressing,  and  often  productive  of  alarm,  is  nevertheless  benefi- 
cial, lessening  the  action  of  the  vessels  in  the  same  way  with  digi- 
talis, the  use  of  which  is  improper  when  this  condition  is  present. 
The  strength  of  the  pulse  is  much  abated  ;  sometimes  it  becomes 
slower;  but  in  general  it  remains  much  as  formerly,  in  point  of 
frequency ;  we  are  therefore  not  to  be  too  anxious  in  removing 
this  condition,  which  restrains  hemorrhage  ;  yet  as  it  may  go  be- 
yond due  bounds  and  produce  dangerous  syncope,  we  must  check 
it  in  time.     We  must  likewise  be  very  attentive  to  the  state  of  the 


295 

discharge  when  this  affection  is  considerable,  for  if,  notwithstand- 
ing this,  the  hemorrhage  should  continue,  it  will  produce  greater 
and  more  immediately  hurtful  effects  than  if  this  were  absent. 

The  best  method  of  abating  this  sinking  and  feebleness,  is  to 
keep  the  body  perfectly  at  rest,  and  the  head  low.  If  necessary, 
we  give  small  quantities  of  stomachic  cordials,  such  as  a  little  tinc- 
ture of  cinnamon,  or  a  few  drops  of  ether  in  a  glass  of  aerated  wa- 
ter ;  or  we  may  give  a  little  peppermint  water,  with  fifteen  drops 
of  tincture  of  opium.  In  urgent  cases,  Madeira  wine  or  undiluted 
brandy  may  be  given  ;  but  these  are  not  to  be  frequently  repeated, 
and  are  very  rarely  necessary.  Large  doses  of  opium  are  also 
useful. 

Sometimes,  instead  of  a  feeling  of  sinking  and  faintness,  the 
fibres  of  the  stomach  are  thrown  into  a  spasmodic  contraction,  pro- 
ducing sudden  and  violent  pain.  This  is  a  most  alarming  symp- 
tom, and  may  kill  the  patient  very  unexpectedly.  It  is  to  be  in- 
stantly attacked  by  a  mixture  of  sulphuric  ether  and  tincture  of 
opium,  in  a  full  dose,  whilst  a  sinapism  is  applied  to  the  epigastric 
region ;  but  if,  when  this  pain  occurs,  there  be  symptoms  of  ap- 
proaching convulsions,  then  bleeding  should  precede  the  anodyne, 
and  no  ether  should  be  given. 

Spasms  about  the  intestines  are  more  frequent,  and  much  less 
dangerous.  They  are  very  readily  relieved  by  thirty  drops  of 
tincture  of  opium,  in  a  dessert-spoonful  of  aromatic  tincture,  or 
forty  drops  of  the  tincture  of  hyoscyamus  in  two  tea-spoonfuls  of 
the  compound  tincture  of  lavender. 

These  disagreeable  symptoms  which  I  have  described,  fortu- 
nately do  not  often  attend  abortion  ;  but  the  process  goes  on  safely, 
and  without  disturbance.  In  this  case,  after  it  is  over,  we  only 
find  it  necessary  to  confine  the  person  to  bed  for  a  few  days,  as 
getting  up  too  soon  is  apt  to  produce  debilitating  discharge.  We 
must  also,  by  proper  treatment,  remove  any  morbid  symptoms 
which  may  be  present,  but  which,  depending  on  the  peculiarities 
of  individuals,  or  their  previous  state  of  health,  cannot  here  be 
specified.  When  the  patient  continues  weakly,  the  use  of  the  cold 
bath,  and  sometimes  of  bark,  will  be  of  much  service  in  restoring 


296 

the  strength;  and,  in  future  pregnancies,  great  care  must  be  taken 
that  abortion  may  not  happen  again  at  the  same  period. 

§  37.  UTERINE  HEMORRHAGE. 

Of  all  the  incidents  to  which  a  pregnant  woman  is  exposed, 
none  is  more  alarming  or  troublesome  than  uterine  hemorrhage, 
when  it  occurs  in  the  advanced  stages  of  gestation,  or  after  the 
delivery  of  the  child.  This,  from  its  extent  and  impetuosity,  has 
aptly  been  called  a  flooding;  and,  from  the  frequency  of  its  occur- 
rence, it  must  be  extremely  interesting  to  every  practitioner. 

The  ovum  is  connected  to  the  uterus  by  means  of  a  vast  multi- 
tude of  delicate  vessels,  which  pass  almost  at  every  point  from  the 
one  to  the  other.  These  vessels  are  large  where  the  placenta  is 
attached;  smaller  where  they  pass  into  the  decidua. 

As  the  ovum  corresponds  exactly  to  the  inner  surface  of  the  ute- 
rus, and  is  in  close  and  intimate  contact  with  it,  we  find  that  as  long 
as  this  union  subsists,  the  vessels,  notwithstanding  their  delicacy, 
are  enabled  to  transmit  blood  without  effusion.  But  whenever  a 
separation  of  the  one  from  the  other  takes  place,  then  these  vessels 
are  either  directly  torn  ;  or,  even  supposing  them  to  extend  a  little, 
they  must  be  ruptured  by  their  own  action,  or  by  the  force  of  the 
blood  which  they  receive  and  circulate.  When  this  happens,  an 
extravasation  or  discharge  must  be  the  consequence,  which  will  be 
greater  or  smaller  in  proportion  to  the  number  and  magnitude  of  the 
vessels  which  have  given  way,  and  the  strength  of  the  action,  which 
exists  in  the  sanguiferous  system. 

The  membranes  are  never  so  full  of  water  as  to  be  put  upon  the 
stretch,  and  therefore  they  cannot  forcibly  distend  the  womb,  and 
make  pressure  on  its  inner  surface.  The  womb  again,  during  ges- 
tation, does  not  embrace  the  membranes  tightly,  so  as  to  compress 
them.  Hence  it  is  evident,  that  when  rupture  first  takes  place,  no 
resistance  can,  by  the  action  of  the  one  upon  the  other,  be  afforded 
to  the  flow  of  the  blood.  The  consequence  of  uterine  hemorrhage, 
when  considerable,  is,  that  the  force  of  the  circulation  is  diminish- 
ed; faintness.  or  absolute  syncope,  being  induced.    The  blood  in 


297 

this  state  flows  more  feebly ;  coagulation  is  allowed  to  take  place., 
and  the  paroxysm  is,  for  the  present,  ended.  This  coagulation, 
in  slight  cases,  may  take  place  even  without  the  intervention  of 
faintness.  Re-union,  however,  when  the  separation  is  extensive, 
and  the  coagulum  considerable,  cannot  be  expected  to  take  place; 
and,  therefore,  when  the  clot  loosens,  a  return  of  the  hemorrhage 
is  in  general  to  be  looked  for. 

One  or  more  copious  discharges  of  blood  must  injure  the 
functions  of  the  uterus,  and  ultimately  destroy,  altogether,  the  ac- 
tion of  gestation.  This  tends  to  excite  the  muscular  action  of  the 
uterine  fibres;  and,  by  their  contraction,  two  effects  will  be  pro- 
duced. The  uterine  vessels  will  be  diminished  in  their  diameter 
or  capacity,  and  the  whole  surface  of  the  womb  pressing  more 
strongly  upon  the  ovum,  a  greater  resistance  will  be  given  to  the 
flow  of  the  blood. 

Thus  it  appears,  that  nature  attempts  to  save  the  patient  in  two. 
ways.  First,  by  the  induction  of  a  state  of  faintness,  or  sometimes 
of  complete  syncope,  which  tends  to  check  the  present  attack- 
Secondly,  when  the  hemorrhage  is  so  great  or  obstinate  as  to  pre- 
vent any  possibility  of  the  woman  going  safely  to  the  full  time, 
such  effects  are  produced  as  tend  to  establish  muscular  contraction, 
and  accelerate  expulsion.  This  double  process  ought,  in  all  our 
reasonings,  to  be  held  in  view. 

Uterine  contraction  is  of  two  kinds,  which  may  be  called  per- 
manent and  temporary.  The  permanent,  is  that  continued  action 
of  the  individual  fibres  by  which  the  uterus  is  rendered  tense,  so 
that  it  feels  hard  if  the  hand  be  introduced  into  its  cavity.  Tho 
temporary,  is  that  greater  contraction  which  is  excited  at  intervals" 
for  the  expulsion  of  the  foetus,  producing  what  are  called  the  pains 
of  labour. 

In  those  cases  where  nature  effects  a  cure  by  expulsion,  or  the 
production  of  labour,  it  is  chiefly  to  the  permanent  or  tonic  con- 
traction that  we  are  indebted  for  the  stoppage  of  hemorrhage  ;  be- 
cause this  contraction  lessens  the  size  of  the  vessels,  and  keeps  up 
a  firm  pressure  of  the  uterine  surface  upon  the  ovum,  until  the 
pains  have  accomplished  the  expulsion  or  delivery  of  the  child. 
The  pains  alone  could  not  do  this  good  ;  for  coming  only  at  inter- 

.39 


298 

vals,  their  effect  would  be  fugacious.  On  the  other  hand,  the 
permanent  contraction  would  not  be  adequate  to  the  purpose,  with- 
out the  pains,  for  these  temporary  paroxysms  excite  this  action  to- 
a  stronger  degree,  and  by  ultimately  forcing  down  the  child,  ac- 
complish delivery  before  the  powers  of  the  uterus  be  worn  out. 

Such  are  the  steps  by  which  the  patient  is  naturally  saved.  But 
we  are  not  to  expect  that  these  shall,  in  every  instance,  or  in  a 
majority  of  instances,  take  place  at  the  proper  time,  or  in  the  due 
degree.  The  debility  and  syncope  may  go  too  far ;  or  the  clots 
may  not  form  in  proper  time,  or  may  come  away  too  soon,  or  too 
easily.  The  action  of  gestation  may  continue,  notwithstanding 
the  violence  of  the  hemorrhage,  thus  preventing  the  accession  of 
muscular  contraction;  or  before  this  contraction  be  established 
and  the  child  expelled,  the  discharge  may  have  been  so  great  and 
constant  as  to  render  the  efforts  of  the  womb  weak  and  inefficient, 
and  by  still  continuing,  may  destroy  them  altogether. 

These  circumstances  being  considered,  it  will  be  evident,  that 
although  when  the  injury  is  small,  and  the  discharge  trifling, 
nature  may  permanently  check  it ;  or  in  more  serious  cases,  may 
preserve  the  woman  by  the  expulsion  of  the  child ;  yet  we  cannot, 
with  prudence,  place  our  whole  reliance  on  her  unassisted  opera- 
tions. 

There  is  also  another  circumstance  relating  to  a  particular  spe- 
cies of  flooding,  which  renders  the  accomplishment  of  a  natural 
cure  or  escape  still  more  doubtful.  This  is,  that  the  placenta  is 
sometimes  attached  to  the  os  uteri,  which  necessarily  must  pro- 
duce a  hemorrhage  whenever  the  cervix  comes  to  be  fully  de- 
veloped, and  the  mouth  to  open. 

The  vessels  going  to  the  placenta  are  much  larger  than  those 
which  enter  the  decidua ;  and  therefore  if  part  of  the  placenta  be 
detached,  the  quantity  and  velocity  of  the  discharge  must  be 
greater,  and  the  effects  more  to  be  dreaded,  than  when  a  part  of 
the  decidua  alone  is  separated.  If  the  placenta  be  fixed  near  the 
cervix  uteri,  and  a  part  of  it  be  detached,  then  the  blood  which  is 
effused  will  separate  the  membranes  down  to  the  os  uteri,  and  a 
profuse  hemorrhage  will  appear.  But  sometimes,  if  it  be  fixed  to 
the  fundus  uteri,  the  blood  may  be  confined,  especially  if  the  sepa- 


299 

lion  have  been  trifling,  and  a  coagulum  will  be  formed  exterior  to 
the  membranes,  the  lower  part  of  which  will  still  adhere  to  the 
uterus ;  or  if  the  central  portion  of  the  placenta  have  been  de- 
tached, a  collection  of  blood  may  be  formed  behind  it,  but  may 
not  extend  beyond  its  circular  margin.  But  if  the  placenta  be 
placed  over  the  os  uteri,  then  the  case  is  different ;  profuse  dis- 
charge will  take  place,  sinking  the  whole  system,  and  very  much 
enfeebling  the  uterus  itself,  so  that  when  uterine  contraction  does 
come  on,  it  will  be  weak,  and  incapable  of  speedily  effecting  ex- 
pulsion ;  even  although  the  contraction  should  be  brisk  and  pow- 
erful, it  cannot,  owing  to  the  structure  of  the  placenta,  do  the  same 
good  as  in  other  cases  of  flooding ;  and  therefore,  in  every  in- 
stance, much  blood  will  be  lost,  and  in  many,  in  very  many,  the 
patient,  if  we  trust  to  this  contraction  alone,  will  perish.  Contrac- 
tion can  only  be  expected  in  this  case  to  do  good,  when  it  is  pow- 
erful, and  the  pains  come  on  so  briskly  as  speedily  to  empty  the 
uterus,  at  the  same  time  that  coagula  shut  the  mouths  of  the  pla- 
cental vessels  at  the  unsupported  part. 

It  has  been  a  common  opinion,  that  flooding  proceeded  always 
from  the  detachment  of  a  part  of  the  placenta ;  but  this  point  is  not 
established.*  In  several  cases  of  uterine  hemorrhage,  the  placenta 
will  be  found  attached  to  the  fundus  uteri ;  and  we  cannot  suppose 
that  in  all  of  these,  the  whole  extent  of  the  membranes,  from  the 
placenta  to  the  os  uteri,  has  been  separated :  yet  this  must  happen 
before  the  discharge  can  in  these  circumstances  appear.  We  can 
often  account  for  the  hemorrhage,  by  supposing  a  portion  of  the  de- 
cidua  to  be  detached  ;  and  we  know  that  the  vessels  about  the  cer- 
vix are  sufficiently  able  to  throw  out  a  considerable  quantity  of 
blood,  if  their  mouths  be  open.    But  in  most  cases  of  profuse  he- 


*  Long  ago,  Andrea  Pasta  questioned  the  opinion,  lhat  Hooding  was  always 
produced  by  separation  of  the  placenta. — Vide  Discorso  del  flusso  di  sangue,  &c. 
We  are  not,  however,  to  suppose,  that  hemorrhage  does  not  proceed  from  de- 
tachment of  the  placenta  in  any  instance  when  it  is  placed  high  up,  but  only  that 
it  is  a  rare  occurrence.  When  the  stream  is  rapid  and  profuse,  we  have  every 
reason  to  suppose  that  part  of  the  placenta  is  separated ;  but  if  we  have  occasion 
to  deliver,  it  will  generally  be  found,  that  it  is  placed  close  by  the  cervix  uteri, 
or  at  least  not  very  far  from  it. 


300 

morrhage,  we  shall  find,  that  the  placenta  is  attached  near  the  os 
uteri,  and  more  or  less  of  it  separated. . 

It  is  possible  for  blood  to  be  effused  in  consequence  of  detach- 
ment of  part  of  the  ovum,  and  yet  it  may  not  be  discharged  by  the 
os  uteri.*  This  detachment  may  be  produced  by  fatigue,  falls, 
blows,  &c.  and  the  effusion  is  accompanied  with  dull  internal  pain 
at  the  spot  where  it  takes  place.  This  pain  is  something  like  colic, 
or  like  pain  attending  the  approach  of  the  menses.  The  part  of  the 
womb  where  the  extravasation  takes  place,  swells  gradually,  and 
the  uterus  in  a  short  time  feels  larger.  If  the  quantity  be  consider- 
able, the  size  increases,  the  uterus  is  firmer  and  tenser,  as  well  as 
larger,  the  strength  diminishes,  and  even  faintings  may  come  on. 
In  course  of  time,  weak  slow  pains  are  felt,  but  if  the  injury  be 
great,  these  decline  as  the  weakness  increases.  They  may  or  may 
not  be  attended  with  the  discharge  of  coagula  from  the  os  uteri.  In 
such  a  case,  it  is  evident,  that  nothing  but  delivery  can  save  the 
mother.  But  if  no  bad  effect  be  produced,  and  the  separation  is 
not  extensive,  the  accident  may  not  be  discerned  or  suspected,  at 
least  till  after  the  child  is  born,  when  often  a  great  quantity  of  blood 
is  evacuated  without  affecting  the  pulse  or  strength,  which  it  would 
do,  did  it  come  recently  from  the  vessels  of  the  uterus. 

Let  us  next  consider  the  causes  giving  rise  to  hemorrhage  in  va- 
rious degrees  j  and  the  first  that  I  shall  mention  is  external  violence, 
producing  a  separation  of  part  of  the  ovum.  As  the  ovum  and  ute- 
rus correspond  exactly  to  each  other,  and  are,  in  the  advanced 
stages  of  gestation,  composed  of  pretty  pliable  materials,  falls  or 
blows  do  not  produce  laceration  so  frequently  as  might  be  sup- 
posed. In  a  majority  of  instances,  the  effect  is  produced  chiefly 
by  the  operation  on  the  vessels,  their  action  being  violently  and 
suddenly  excited,  and  rupture  of  their  eoats  thus  produced.  When 
the  ovum  is  mechanically  detached,  the  injury  must  have  been  con- 
siderable, and  in  general  the  foetus  is  destroyed. 

Fatigue  or  much  exertion  may  injure  the  action  of  the  uterus,, 
and  give  rise  to  premature  expulsion,  which  in  this  case  is  gene- 

*  Vide  Albinus  Acad.  Annot.  lib.  I.  p.  58.  Recueil  Periodique,  torn.  ii.  p.  15. 
and  torn.  iii.  p.  1. 


501 

rally  attended  with  considerable  discharge.  Such  exertions  are 
likewise  apt,  by  their  effect  on  the  circulation,  to  operate  on  the. 
vessels  passing  to  the  ovum,  and  produce  in  them  a  greater  degree 
of  activity  than  they  are  capable  of  sustaining  without  rupture.  It 
is,  therefore,  very  properly  laid  down  as  a  rule  of  practice,  to  forbid 
pregnant  women  to  undergo  much  fatigue,  or  exert  any  great  mus- 
cular action ;  and  wherever  this  rule  has  been  departed  from,  es- 
pecially by  a  patient  of  an  irritable  or  of  a  plethoric  habit,  it  be- 
hooves the  practitioner  to  attend  carefully  to  the  first  appearances  of 
injury,  or  to  the  first  symptoms  of  decay  in  the  uterine  action. 
Rest,  and  an  opiate,  will  upon  general  principles  be  indicated,  and 
when  the  circulation  is  affected,  or  we  apprehend  increased  action 
about  the  uterine  vessels,  venesection  must  be  premised,  and  the 
patient  kept  cool  and  tranquil. 

Violent  straining  at  stool,  or  strong  exertions  of  the  abdominal 
muscles,  made  in  lifting  heavy  bodies,  or  in  stretching  to  a  height, 
or  frequent  and  continued  stooping,  may  all,  by  compressing  the 
womb,  cause  separation.  For  the  greatest  effect  will  be  produced 
where  the  resistance  is  least,  or  the  support  smallest,  which  is  at  the 
under  part  of  the  uterus,  and  there  rupture  will  be  apt  to  take  place. 

A  preternatural  degree  of  action  in  the  vessels  going  to  the  pla- 
centa or  decidua,  must  be  dangerous,  and  likely  to  produce  rupture 
and  extravasation.  This  may  either  be  connected  with  a  general 
state  of  the  vascular  system,  marked  by  plethora,  or  by  arterial  ir- 
ritation ;  or  it  may  be  more  immediately  dependent  on  the  state  of 
the  uterus  itself. 

When  the  patient  is  plethoric,  or  when  the  action  of  the  vascular 
system  is  increased,  it  is  natural  to  suppose,  that  the  effect  will  be 
greatest  on  those  parts  of  the  womb  which  are  in  the  highest  state 
of  activity.  These  are  chiefly  two ;  the  part  to  which  the  placen- 
ta is  attached,  for  there  the  vessels  are  large  and  numerous;  and  the 
cervix  and  os  uteri,  because  there  the  greatest  changes  are  going 
forward.  At  one  or  other  of  these  two  places,  rupture  is  most 
likely  to  take  place,  and  it  will  happen  still  more  readily  if  the 
placenta  be  attached  at  or  near  to  the  cervix.  It  may  be  excited 
either  by  too  much  blood  circulating  permanently  in  the  system, 
pr  by  a  temporary  increase  of  the  strength  and  velocity  of  the  circu- 


302 

lation,  produced  by  passion,  agitation,  stimulants,  &ic.  A  plethoric 
state  is  a  frequent  cause  of  hemorrhage  in  the  young,  the  vigorous, 
and  the  active  ;  the  decidua  is  separated,  and  a  considerable  quan- 
tity of  blood  flows ;  perhaps  the  placenta  is  detached,  and  the  he- 
morrhage is  more  alarming.  In  some  cases,  the  rupture  is  preceded 
by  spitting  of  blood,  or  bleeding  at  the  npse,  and  in  these  cases  the 
lancet  may  be  of  much  service. 

We  sometimes  find  that  extravasation  is  produced  by  an  increas- 
ed action  of  the  uterine  vessels  themselves,  existing  as  a  local  dis- 
ease. In  this  case,  the  patient,  for  some  time  before  the  attack, 
feels  a  weight  and  uneasy  sensation  about  the  hypogastric  region, 
with  slight  darting  pains  about  the  belly  or  back.  These  precur- 
sors have  generally  been  ascribed  to  a  different  cause  ;  namely,  ri- 
gidity of  the  ligaments  of  the  womb  or  of  the  fibres  of  the  uterus 
itself. 

Spasmodic  action  about  the  os  uteri,  must  produce  a  separation 
of  the  connecting  vessels.  The  causes  giving  rise  to  this  in  the 
advanced  period  of  gestation,  are  not  always  obvious,  neither  can 
we  readily  determine  the  precise  cases  in  which  this  action  excites 
flooding.  We  should  expect  that  the  discharge  ought  always  to  be 
preceded  by  pain,  but  we  know  that  motion  may  take  place  in 
some  instances  about  the  os  uteri  without  much  sensation  ;  and,  on 
the  other  hand,  many  cases  of  flooding,  not  dependent  on  mo- 
tion of  the  uterine  fibres,  are  attended  with  uneasiness  or  irregu- 
lar pain  about  the  abdomen.  This  spasmodic  action  is  not  unfre- 
quently  produced  by  hanging  pregnant  animals. 

Whatever  stops  prematurely  the  action  of  gestation,  may  give 
rise  to  a  greater  or  less  degree  of  hemorrhage.  For  in  this  case, 
the  development  of  the  cervix  takes  place  quickly,  and  the  ovum 
must  be  separated.  The  quantity  of  the  discharge*  will  depend 
upon  the  state  of  the  circulation — the  magnitude  of  the  vessels 
which  are  torn — the  contraction  of  the  uterus — and  the  care  which 
is  taken  of  the  patient.     Hence  it  follows  as  a  rule  in  every  pre- 

*  In  those  cases  where  the  contraction  becomes  universal  and  effective,  we 
have  little  discharge,  and  the  patient  is  merely  said  to  have  a  premature  labour ; 
but  if  the  contraction  be  partial,  and  do  not  soon  become  effective,  then  we  have 
considerable  discharge,  and  the  patient  is  said  to  have  a  flooding. 


303 

mature  labour,  more  especially  in  its  first  stage,  that  we  prevent  all 
exertion,  refrain  from  the  use  of  stimulants,  and  confine  the  pa- 
tient to  a  recumbent  posture. 

It  sometimes  happens,  that  effective  contraction  does  not  take 
place  speedily  after  the  action  of  gestation  ceases,  but  a  discharge 
appears.  This  may  stop  by  the  induction  of  syncope,  or  the  for- 
mation of  clots.  The  blood  which  is  retained  about  the  cervix  and 
os  uteri  putrefying,  produces  a  very  offensive  smell.  Milk  is  se- 
creted as  if  delivery  had  taken  place,  and  sometimes  fever  is  ex- 
cited. In  this  state  the  patient  may  remain  for  some  days,  when 
the  hemorrhage  is  renewed,  and  the  patient  may  be  lost  if  we  do 
not  interfere. 

Some  undue  state  of  action  about  the  os  uteri,  removing  or  ceas- 
ing to  form  that  jelly  which  naturally  ought  to  be  secreted  there,  is 
another  cause. 

This  is  generally  productive  of  a  discharge  of  watery  fluid,  tinged 
with  blood  ;  and  if  the  patient  be  not  careful,  pure  blood  may  be 
thrown  out  in  considerable  quantity.  It  may  even  happen,  that 
the  hemorrhage,  under  certain  circumstances,  may  prove  fatal ; 
and  yet,  upon  dissection,  no  separation  of  the  ovum  be  discover- 
ed, the  discharge  taking  place  from  the  vessels  about  the  os  uteri 
itself* 

In  some  instances  where  a  portion  of  the  placenta  has  been  de- 
tached, I  have  observed,  that  near  the  separated  part,  the  struc- 
ture of  the  placenta  was  morbid,  being  hard  and  gristly.  In  these 
cases,  I  could  not  detect  any  other  cause  of  separation,  and  sup- 
pose that  by  the  accidental  pressure  of  the  child  upon  the  indurat- 
ed part,  the  uterus  may  have  been  irritated. 

The  insertion  of  the  placenta  over  the  os  uteri,f  may  give  rise 
Co  flooding  in  different  ways. 

*  Vide  a  case  in  point,  by  M.  Heinigke,  in  the  first  volume  of  Brewer's  Bib- 
fioth.  Germ. 

|  So  far  as  I  have  observed,  uterine  hemorrhage,  when  profuse,  is  produced 
most  frequently  by  this  cause;  at  least  two-thirds  of  those  cases  requiring  delive- 
ry, proceed,  I  think,  from  the  presentation  of  the  placenta  ;  and  in  the  majority 
of  the  remaining  third,  it  will  be  found  attached  near  to  the  cervix.  Most  of  those 
hepiorrhages,  which  are  cured  without  delivery,  proceed  from  the  detachment  of 


304 

The  uterus  and  placenta  may  remain  in  contact  until  the  term 
of  natural  labour,  the  one  adapting  itself  to  the  other ;  but  when- 
ever the  os  uteri  begins  to  dilate,  separation  and  consequent  he- 
morrhage must  take  place.  It  is  rare,  however,  for  the  accident  to 
be  postponed  so  long.  In  general,  at  an  earlier  period,  in  the 
eighth,  or  by  the  middle  of  the  ninth  month,  we  find  that  either 
the  uterus  and  placenta  no  longer  grow  equally,  in  consequence  of 
which  the  fibres  about  the  os  uteri  are  irritated  to  act ;  or  so  much 
blood  as  must  necessarily,  in  this  situation,  circulate  about  the  cer- 
vix uteri,  interferes  with  its  regular  actions,  and  induces  premature 
contraction  of  its  fibres,  with  a  consequent  separation  of  the  con- 
necting vessels. 

In  order  to  ascertain  whether  the  hemorrhage  proceed  from  this 
cause,  we  ought,  in  every  case  to  which  we  are  called,  carefully  to 
examine  our  patient.  The  introduction  of  the  finger  is  sometimes 
sufficient  for  this  purpose,  but  frequently  it  may  be  necessary  to 
carry  the  whole  hand  into  the  vagina. 

If  the  placenta  present,  we  shall  feel  the  lower  part  of  the  uterus 
thicker  than  usual,  and  the  child  cannot  be  so  distinctly  perceived 
to  rest  upon  it.  This  is  ascertained  by  pressing  with  the  finger  on 
the  fore  part  of  the  cervix,  betwixt  the  os  uteri  and  bladder,  and 
also  a  little  to  either  side.* 

If  the  os  uteri  be  a  little  open,  then,  by  insinuating  the  finger, 
and  carrying  it  through  the  small  clots,  we  may  readily  ascertain 
whether  the  placenta  or  membranes  present,  by  attending  to  the 
difference  which  exists  betwixt  them.  But  in  this  examination,, 
we  must  recollect,  that  only  a  small  portion  of  the  edge  of  the  pla- 
centa may  present,  and  this  may  not  readily  be  felt  at  first. 

To  conclude  this  part  of  the  subject,  I  remark,  in  general,  that 
hemorrhage  from  the  uterus  is  not  merely  arterial,  but  also  vein- 

the  decidua  alone,  or  of  a  very  small  portion  of  the  placenta,  which  has  been  se- 
parated under  circumstances  favourable  for  firm  coagulation. 

*  When  a  large  coagulum  occupies  the  lower  part  of  the  uterus,  we  may  be 
deceived  it  we  trust  to  external  feeling  alone,  without  introducing  the  finger  with- 
in the  os  uteri.  If  the  uterus  have  its  usual  feel,  and  the  child  be  felt  distinctly 
through  it,  then  we  are  sure  that,  however  near  the  placenta  may  be  to  the  os 
uteri,  it  is  not  fixed  exactly  over  it. 


305 

ous,  and  the  orifices  of  these  latter  vessels  are  extremely  large. 
Almost  immediately  after  conception,  the  veins  enlarge  and  dilate, 
contributing  greatly  to  give  to  the  uterus  the  doughy  feel  which  it 
possesses.  In  the  end  of  gestation  the  sinuses  are  of  immense  size, 
and  their  extremities  so  large  that  in  many  places  they  will  admit 
the  point  of  the  finger.  Now,  as  all  the  veins  communicate  more 
freely  than  the  arteries,  and,  as  they  have  in  the  uterus  no  valves, 
we  can  easily  conceive  the  rapidity  with  which  discharge  will  take 
place,  and  the  necessity  of  encouraging  coagulation,  which  checks- 
veinous  still  more  readily  than  arterial  hemorrhage. 

In  whatever  way  flooding  is  produced,  it  has  a  tendency  to  in- 
jure or  disturb  gestation,  and  to  excite  expulsion;  but  these  effects 
may  be  very  slowly  accomplished,  and  in  a  great  many  instances 
may  not  take  place  in  time  to  save  the  patient  or  her  child. 
Having  already  noticed  those  changes  produced  on  the  womb  it- 
self by  hemorrhage,  and  the  danger  of  trusting  to  them  for  the  re- 
covery of  the  patient,  I  will  not  recapitulate,  but  proceed  verv 
shortly  to  mention  the  effects  produced  on  the  system  at  large. 

During  the  continuance  of  the  hemorrhage,  or  by  the  repetition 
of  the  paroxysms,  if  this  be  allowed  to  take  place,  certain  altera- 
tions highly  important  are  taking  place.  There  is  much  less  blood 
circulating  than  formerly;  and  this  blood,  when  the  hemorrhage 
has  been  frequently  renewed,  is  less  stimulating  in  its  properties, 
and  less  capable  of  affording  energy  to  the  brain  and  nerves.  The 
consequence  of  this  is,  that  all  the  actions  of  the  system  must  be 
performed  more  languidly,  and  with  less  strength.  The  body  is 
much  more  irritable  than  formerly,  and  slight  impressions  produce 
greater  effects.  This  gives  rise  to  many  hysterical,  and  sometimes 
even  to  convulsive  affections.  The  stomach  cannot  so  readily  di- 
gest the  food — the  intestines  become  more  sluggish — the  heart 
beats  more  feebly — the  arteries  act  with  little  force — the  muscular 
fibres  contract  weakly — the  whole  system  descends  in  the  scale  of 
action,  and  must,  if  the  expression  be  allowable,  move  in  an  infe- 
rior sphere.  In  this  state,  very  slight  additional  injury  will  sink 
the  system  irreparably — very  trifling  causes  will  unhinge  its  ac- 
tions, and  render  'them  irregular.  If  the  debility  be  carried  to  a 
degree  farther,  no  care  can  recruit  the  system — no  means  can  re- 

10 


306 

new  the  vigour  of  the  uterus.  We  may  stop  the  hemorrhage,  but 
recovery  will  not  take  place.  We  may  deliver  the  child,  but  the 
womb  will  not  contract.  If  when  the  system  is  debilitated  by  he- 
morrhage, some  irritation  be  conjoined,  then  the  muscular  action 
becomes  more  or  less  irregular,  and  an  approximation  is  made  to 
a  state  of  fever.  The  pulse  is  feeble,  but  sharp ;  the  skin  rather 
warm ;  and  the  tongue  more  or  less  parched.  This  state  of  the 
vascular  system  is  dangerous,  both  as  it  exhausts  still  more  a  frame 
already  very  feeble,  and  also  as  it  tends  to  renew  the  hemorrhage. 
It  will  often  be  found  to  depend  upon  slight  uterine  irritation,  upon 
accumulation  in  the  bowels,  upon  pulmonic  affections,  upon  mus- 
cular pain,  or  upon  the  injudicious  application  of  stimuli. 

Such  organs  as  have  been  previously  disposed  to  disease,  or 
have  been  directly  or  indirectly  injured  during  the  continuance  of 
protracted  flooding,  may  come  to  excite  irritation,  and  give  consi- 
derable trouble. 

An  acute  attack  of  hemorrhage  generally  leaves  the  patient  in 
a  state  of  simple  weakness ;  but  if  the  discharge  be  allowed  to  be 
frequently  conjoined,  and  the  case  thus  protracted,  some  irritation 
often  comes  to  be  produced,  which  adds  to  the  danger,  and  excites, 
if  the  patient  be  not  delivered,  more  speedy  returns. 

A  woman  seldom  suffers  much  in  a  first  attack  of  hemorrhage. 
If  she  be  stout  and  plethoric,  she  may  lose  a  great  quantity  of 
blood,  and  yet,  to  appearance,  not  be  greatly  injured.  The  hemor- 
rhage may  come  on  in  every  different  situation ;  in  bed  she  may 
awake  suddenly  from  a  dream,  and  feel  herself  swimming  in 
blood ;  or  it  may  attack  her  when  walking ;  or  may  be  pre- 
ceded by  a  desire  to  make  water,  and  she  is  surprised  to  find 
the  chamber-pot  half  filled  with  blood.  She  recovers  from  her 
consternation ;  perhaps  in  spite  of  every  injunction,  she  walks 
about  as  usual,  and  finds  no  bad  effect  from  motion ;  the  feel- 
ing of  heaviness  which  may  have  preceded  the  accident,  is 
gone,  she  is  lighter  and  better  than  she  was  before  it,  and  hopes 
all  is  well;  but  in  a  few  days  the  hemorrhage  is  repeated,  and 
again  stops ;  at  last,  after  one  or  two  attacks,  for  the  time  is 
uncertain,  the  os  uteri  become  soft,  and  opens  a  little,  perhaps 
without  pain,  or  she  feels  dull  slight  pains,  which,  however,  give 
her  very  little  uneasiness.     This  state  may  take  place  early,  and 


307 

without  dangerous  debility;  it  may  take  place  in  the  second  or 
third  attack  ;  or,  possibly,  the  hemorrhage  may  never  have  entirely 
ceased,  continuing  for  a  day  or  two  like  a  flow  of  the  menses,  and 
then  being  suddenly  increased,  or  flowing  in  a  torrent.  But,  al- 
though this  state  may  take  place  without  alarming  debility,  it  may 
also,  and  that  very  suddenly,  be  attended  with  the  utmost  danger, 
or  may  be  accompanied  with  so  much  hemorrhage  as  to  prove  ab- 
solutely fatal.  The  patient  is  found  without  a  drop  of  blood  in  her 
face,  the  extremities  cold,  die  pulse  almost  gone,  the  stomach  una- 
ble to  retain  drink.  She  is  in  the  last  stage  of  weakness,  but  it  is 
not  the  weakness  produced  by  fever  or  disease,  for  we  find  her 
voice  good,  and,  generally,  the  intellect  clear.  The  hemorrhage 
has,  perhaps,  stopped,  and  a  young  man  would  suppose  it  still 
possible  for  her  to  recover.  But,  although  not  a  drop  of  blood  is 
afterwards  lost,  the  debility  increases,  the  pulse  is  quite  gone,  she 
breathes  with  difficulty,  and  gives  long  sighs,  wavers  in  her  speech, 
and  in  a  short  time  expires. 

We  may  lay  it  down  as  a  general  observation,  that  few  cases  of 
profuse  hemorrhage,  occurring  in  an  advanced  stage  of  gestation, 
can  be  cured  without  delivery  or  the  expulsion  of  the  child.  For 
when  the  discharge  is  copious  or  obstinate,  the  placenta  is  gene- 
rally separated,  sometimes  to  a  very  considerable  extent,  and  a  re- 
union," without  which  the  woman  can  never  be  secure  against 
another  attack,  can  rarely  be  expected.  If  the  placenta  present, 
the  hemorrhage,  although  suspended,  will  yet  to  a  certainty  return, 
and  few  shall  survive  if  the  child  be  not  delivered. 

But  in  those  cases  where  only  a  portion  of  the  decidua,  or  a 
little  bit  of  the  margin  of  the  placenta*  has  been  detached,  and 
the  communicating  vessels  opened,  either  by  a  state  of  over-action 
in  the  vascular  system,  or  by  too  much  blood  in  the  vessels,  or  by 
some  mechanical  exertion,  if  proper  care  be  taken,  the  hemor- 
rhage may  be  completely  and  permanently,  checked ;  or  if  it 
should  return,  it  may  be  kept  so  much  under,  or  may  consist  sa 
much  of  the  watery  discharge  from  the  glands  about  the  os  uteri, 

*  In  this  case,  after  labour  is  over,  we  may  discover  the  separated  portion  by 
the  difference  of  colour ;  it  is  generally  browner  and  softer  than  the  rest. 


308 

as  neither  to  interfere  with  gestation,  nor  injure  the  constitution; 
yet  it  is  to  be  recollected,  that  even  these  cases  of  flooding  may 
sometimes  proceed  to  a  dangerous  degree,  requiring  very  active 
and  decided  means  to  be  used;  and  in  no  case  can  the  patient  be 
considered  as  safe,  unless  the  utmost  care  and  attention  be  paid  to 
her  conduct. 

It  would  thus  appear,  that  some  hemorrhages  almost  inevitably 
end  either  in  the  delivery  of  the  child,  or  the  death  of  the  parent; 
whilst  others  may  be  checked  or  moderated  without  an  operation. 
A  precise  diagnostic  line,  liable  to  no  exceptions,  cannot  be  drawn 
betwixt  these  cases;  and  therefore,  whilst  we  believe  that  rapid 
and  profuse  hemorrhages,  which  indicate  the  rupture  of  large  ves- 
sels, can  seldom  be  permanently  checked,  we  still,  provided  the 
placenta  do  not  present,  are  not  altogether  without  hopes  of  that 
termination,  which  is  more  desirable  for  the  mother,  and  safer  for 
the  child,  than  premature  delivery.  In  slighter  cases,  our  hope  is 
joined  with  some  degree  of  confidence. 

A  second  attack,  especially  if  it  follow  soon  after  the  first,  and 
from  a  slight  cause,  or  without  any  apparent  cause,  greatly  dimin- 
ishes the  chance  of  carrying  the  woman  to  a  happy  conclusion 
without  manual  interference. 

In  forming  our  opinion  respecting  the  immediate  danger  of  the 
patient,  we  must  consider  her  habit  of  body,  and  the  previous  state 
of  her  constitution.  We  must  attend  to  the  state  of  the  pulse,  con- 
necting that  in  our  mind  with  the  quantity  and  rapidity  of  the  dis- 
charge. A  feeble  pulse,  with  a  hemorrhage,  moderate  in  regard 
to  quantity  and  velocity,  will,  if  the  patient  have  been  previously  in 
good  heakh,  generally  be  found  to  depend  on  some  cause,  the  con- 
tinuance of  which  is  only  temporary.  But  when  the  weakness  of 
the  pulse  proceeds  from  profuse  or  repeated  hemorrhage,  then  al- 
though it  may  sometimes  be  rendered  still  more  feeble  by  oppres- 
sion, or  feeling  of  sinking  at  the  stomach  ;  yet,  when  this  is  reliev- 
ed, it  does  not  become  firm.  It  is  easily  compressed,  and  easily 
affected  by  motion ;  or,  sometimes,  even  by  raising  the  head. 

If  the  paroxysm  is  to  prove  fatal,  the  debility  increases — the 
pulse  flutters  and  becomes  imperceptible — the  extremities  first, 
and  then  the  whole  body,  become  cold  and  clammy — the  breath- 


30$ 

ing  is  performed  with  a  sigh — she  calls  to  be  raised  and  have  the 
windows  opened — is  in  constant  motion,  with  great  anxiety,  per- 
haps vomits — and  syncope  closes  the  scene. 

If  irritation  be  conjoined  with  hemorrhage,  then  the  pulse  is 
sharper,  and,  although  death  be  near,  it  is  felt  more  distinctly  than 
when  irritation  is  absent. 

The  termination  in  this  case  is  often  more  sudden  than  a  person, 
unacquainted  with  the  effect  of  pain  and  irritation  on  the  pulse, 
would  suppose.  For  when  the  pulsation  is  distinct,  and  even  ap- 
parently somewhat  firm,  a  slight  increase  of  the  discharge,  or  some- 
times an  exertion  without  discharge,  speedily  stops  it,  the  heat  de- 
parts, and  the  patient  never  gets  the  better  of  the  attack. 

We  must  likewise  remember,  that  a  discharge,  which  takes  place 
gradually,  can  be  better  sustained  than  a  smaller  quantity,  which 
flows  more  rapidly.  For  the  vessels  in  the  former  case  come  to 
be  accustomed  to  the  change,  and  are  able  more  easily  to  accom- 
modate themselves  to  the  decreased  quantity.  But  when  blood  is 
lost  rapidly,  then  very  speedy  and  universal  contraction  is  required 
in  the  vascular  system,  in  order  that  it  may  adjust  itself  to  its  contents, 
and  this  is  always  a  debilitating  process.  The  difference  too  be- 
twixt the  former  and  the  present  condition  of  the  body,  is  rapidly 
produced,  and  has  the  same  bad  effect  as  if  we  were  instantly  to 
put  a  free  liver  upon  a  very  low  and  abstemious  diet. 

In  all  cases  of  flooding,  we  find,  that  during  the  paroxysm,  the 
pulse  flags,  and  the  person  becomes  faint.  Complete  syncope  may 
even  take  place  ;  but  this  in  many  cases  is  more  dependent  on  sick- 
ness or  oppression  at  the  stomach,  than  on  direct  loss  of  blood.  In 
delicate  and  irritable  habits,  the  number  of  fainting  fits  may  be 
great,  but  unless  the  patient  be  much  exhausted,  we  generally  find 
that  the  pulse  returns,  and  the  strength  recruits.  The  prognosis 
here  must  depend  greatly  on  the  quantity  and  velocity  of  the  dis- 
charge ;  for  it  may  happen,  that  the  first  attack  of  hemorrhage 
may  produce  a  syncope,  from  which  the  patient  is  never  to  re- 
cover. 

When  we  are  called  to  a  patient  recently  attacked  with  flooding, 
our  most  obvious  duty  is  immediately  to  restrain  the  violence  of 
the  discharge;  after  which  we   can  take  such  measures  as  the 


310 

nature  of  the  case  may  demand,  either  for  preserving  gestation,  or 
for  hastening  the  expulsion  of  the  child. 

A  state  of  absolute  rest,  in  a  horizontal  posture,  is  to  be  enforced 
with  great  perseverance,  as  the  first  rule  of  practice.  By  rest 
alone,  without  any  other  assistance,  some  hemorrhages  may  be 
cured ;  but  without  it,  no  woman  can  be  safe.  Even  after  the 
immediate  alarm  of  the  attack  is  over,  the  woman  must  still  recol- 
lect her  danger.  She  should  be  confined  to  bed,  upon  a  firm 
mattress  for  several  days,  and  ought  not  to  leave  her  apartment 
for  a  much  longer  period. 

In  general,  the  patient  has  gone  to  bed  before  we  are  called  ; 
and,  perhaps,  by  the  time  that  we  arrive,  the  bleeding  has  in  a 
great  measure  ceased.  The  partial  unloading  of  the  vessels,  pro- 
duced by  the  rupture,  the  induction  of  a  state  approaching  to  syn- 
cope in  consequence  of  the  discharge,  the  fear  of  the  patient,  and 
a  horizontal  posture,  may  all  have  conspired  to  stop  the  hemor- 
rhage. 

The  immediate  alarm  from  the  flooding  having  subsided,  the  pa- 
tient often  expresses  herself  as  more  apprehensive  of  premature  la- 
bour, than  of  the  hemorrhage,  which  she  considers  as  over.  If  the 
attack  have  been  accompanied  with  slight  abdominal  pain,  her  fears 
are  confirmed.  But  we  are  not  to  enter  into  these  views  of  the 
case ;  we  are  to  consider  the  discharge  as  the  prominent  symptom, 
as  the  chief  source  of  danger.  We  are  to  look  upon  the  present 
abatement  as  an  uncertain  calm ;  and  whatever  advice  we  may 
give,  whatever  remedies  we  may  employ,  we  are  not  to  leave  our 
patient  until  we  have  strongly  enforced  on  her  attendants  the  dan- 
ger of  negligence,  and  the  necessity  of  giving  early  intimation 
should  the  hemorrhage  be  renewed.  There  is  no  disease  to  which 
the  practitioner  can  be  called,  in  which  he  has  greater  responsibi- 
lity than  in  uterine  hemorrhage.  The  most  prompt  and  decided 
means  must  be  used;  the  most  patient  attention  must  be  bestowed; 
and,  whenever  he  undertakes  the  management  of  a  case  of  this 
kind,  whatever  be  the  situation  of  the  patient,  he  must  watch  her 
with  constancy,  and  forget  all  considerations  of  gain  and  trouble. 
His  own  reputation,  his  peace  of  mind,  the  life  of  his  patient,  and 
that  of  her  child,  are  all  at  stake.   I  am  doing  the  student  the  most 


311 

essential  service,  when  I  earnestly  press  upon  his  attention  these 
considerations.  And  when  1  intreat,  implore  him  to  weigh  well 
the  proper  practice  to  be  pursued,  the  necessary  care  to  be  be- 
stowed, I  am  pleading  for  the  existence  of  his  patient,  and  of  his 
own  honour  and  happiness.  Procrastination,  irresolution,  or  timi- 
dity, have  hurried  innumerable  victims  to  the  grave ;  whilst  the 
rash  precipitation  of  unfeeling  men  has  only  been  less  fatal,  because 
negligence  is  more  common  than  activity. 

I  shall  endeavour  to  point  out  the  proper  treatment  in  the  com- 
mencement of  uterine  hemorrhage,  and  the  best  method  of  termi- 
nating the  case  when  the  patient  cannot  be  conducted  with  safety 
to  the  full  time.  After  the  patient  is  laid  in  bed,  it  is  next  to  be 
considered  how  the  hemorrhage  is  to  be  directly  restrained,  and 
whether  we  may  be  able  to  prevent  a  return.  It  is  at  all  times  pro- 
per to  ascertain  exactly  the  situation  of  the  patient  by  examination, 
as  we  thus  learn  the  state  of  the  cervix  and  os  uteri,  and  whether 
there  be  any  tendency  to  labour;  whether  the  discharge  be  stopped 
by  a  coagulum  in  the  mouths  of  the  vessels,*  or  by  a  large  clot  in 
the  upper  part  of  the  vagina ;  whether  the  placenta  be  attached  to 
the  os  uteri,  or  whether  the  membranes  present.  We  likewise  en- 
deavour to  ascertain  the  quantity  of  blood  which  has  been  lost — 
the  rapidity  with  which  it  flowed — the  effect  which  it  has  produced 
upon  the  mother  or  child — and  the  cause  which  appeared  to  excite 
the  hemorrhage. 

The  first  remedy  which,  upon  a  general  principle,  offers  itself  to 
our  attention,  is  blood-letting.  In  those  cases,  where  the  attack  has 
been  produced  by  over-action  of  the  vessels,  or  a  plethoric  condi- 
tion ;  or  where  it  seems  to  be  kept  up  by  these  causes,  this  remedy 
employed  early,  and  followed  by  other  means,  may  be  effectual  noi 
only  in  checking  the  present  paroxysm,  but  also  in  preventing  a  re- 
turn. By  the  timely  and  decided  use  of  the  lancet,  much  distress  may 
be  avoided,  and  both  the  mother  and  the  child  may  be  saved  from 

*  We  may  conjecture  that  this  is  the  case,  if  we  find  no  clot  in  the  vagina 
plugging  the  os  uteri.  We  are  not  warranted  to  thrust  the  finger  forcibly  within 
the  os  uteri,  in  this  examination  ;  or  to  rub  away  the  small  coagula  which  may  be 
formed  within  it,  and  which  may  be  restraining  the  hemorrhage. 


312 

danger.  But  we  are  not  to  apply  the  remedy  for  one  state  to  every 
condition;  we  must  have  regard  to  the  cause,  and  consider  how  far 
the  hemorrhage  is  kept  up  by  plenitude  or  morbid  activity  of  the 
vessels.  In  those  cases  where  the  attack  is  not  excited  by,  or  con- 
nected with,  plethora,  or  undue  action  in  the  vascular  system,  ve- 
nesection is  not  indicated.  We  have  in  these  cases,  which  are,  I 
believe,  by  far  the  most  numerous,  other  means  of  safely,  and  pow- 
erfully moderating  vascular  action,  without  the  detraction  of  blood, 
which,  in  this  disease,  it  ought  to  be  a  leading  principle  to  save  as 
much  as  possible  ;  and  it  must  be  impressed  on  the  student,  that 
venesection  is  rarely  required  in  the  disease  in  question.  Whatever 
lessens  materially  or  suddenly  the  quantity  of  blood,  must  dirjectly 
enfeeble,  and  call  for  a  new  supply,  otherwise  the  system  suffers 
for  a  long  time. 

We  shall  find,  that  except  under  those  particular  circumstances 
which  I  have  specified,  and  where  we  have  ground  to  believe  that 
the  rupture  of  vessels  has  been  dependent  on  their  plenitude  or 
over-action,  the  circulation  may  be  speedily  moderated  by  other 
means,  and  especially  by  the  application  of  cold.  This  is  to  be 
made  not  only  by  applying  cloths  dipped  in  cold  water  to  the  back 
and  vulva,  but  also  by  sponging  over  the  legs,  arms,  and  even  the 
trunk,  with  any  cold  fluid;  covering  the  patient  only  very  lightly 
with  clothes,  and  promoting  a  free  circulation  of  cold  air,  until  the 
effect  upon  the  vessels  be  produced.  After  this  we  shall  find  no 
advantage,  but  rather  harm  from  the  further  application  of  cold. 
All  that  is  now  necessary,  is  strictly  and  constantly  to  watch  against 
the  application  of  heat,  that  is,  raising  the  temperature  above  the 
natural  standard. 

The  extent  to  which  this  cooling  plan  is  to  be  carried,  must  de- 
pend upon  circumstances.  In  a  first  attack,  it  is  in  general  to  be  used 
in  all  its  vigour;  but  where  the  discharge,  either  towards  the  end 
of  this  attack,  or  in  a  subsequent  paroxysm,  has  gone  so  far  as  to 
reduce  the  heat  much  below  the  natural  standard,  the  vigorous 
application  of  cold  might  sink  the  system  too  much.  In  some 
urgent  cases  it  may  even  be  necessary  to  depart  from  our  general 
rule,  and  apply  warm  cloths  to  the  hands,  feet,  and  stomach.  This 
is  the  case  where  the  discharge  has  been  excessive,  and  been  suf- 


313 

J'ered  to  continue  profuse  or  for  a  long  time,  and  where  wc  are 
afraid  that  the  system  is  sinking  fast,  and  the  powers  of  life  giving 
way.  There  are  cases  in  which  some  nicety  is  required  in  deter- 
mining this  point,  and  in  these  circumstances  we  must  never  leave 
our  patient,  but  must  watch  the  effects  of  our  practice.  This  is  a 
general  rule  in  all  hemorrhages,  whatever  their  cause  may  have 
been,  or  from  whatever  vessel  the  blood  may  come.  A  cold  skin 
and  a  feeble  pulse  never  can  require  the  positive  and  vigorous  ap- 
plication of  cold;  but  on  the  other  hand,  they  do  not  indicate  the 
application  of  heat,  unless  they  be  increasing,  and  the  strength  de- 
clining. Then  we  cautiously  use  heat  to  preserve  what  remains, 
not  rashly  and  speedily  to  increase  action  beyond  the  present 
state  of  power. 

When  an  artery  is  divided,  it  is  now  the  practice  to  trust  for  a 
cure  of  the  hemorrhage  to  compression,  applied  by  a  ligature. 
We  cannot,  however,  apply  pressure  directly  and  mechanically  to 
the  uterine  vessels,  but  we  can  promote  coagulation,  which  has 
the  same  immediate  effect.  Rest  and  cold  are  favourable  to  this 
process,  but  ought  only  in  slight  cases  to  be  trusted  to  alone.  In 
this  country  it  has  been  the  practice  to  depend  very  much  upon 
the  application  to  the  back  or  vulva,  of  cloths  dipped  in  a  cold 
fluid,  generally  water,  or  vinegar  and  water;  but  these  are  not 
always  effectual,  and  sometimes,  from  the  state  of  the  patient,  are 
not  admissible.  Astringent  injections  are  seldom  of  benefit  in  any 
discharge  which  deserves  the  name  of  hemorrhage.  They  com* 
monly  do  good  in  a  stillicidium,  rather  troublesome  from  its  du- 
ration, than  hazardous  from  its  extent.  In  urgent  cases  they  are 
hurtful,  by  washing  away  coagula. 

Plugging  the  vagina  with  a  soft  handkerchief,*  answers  every 

•  The  insertion  of  a  small  piece  of  ice  in  the  first  fold  of  the  napkin,  is  attend- 
ed with  great  advantage,  and  has  often  a  very  powerful  effect.  Dr.  Hoffman 
employed  the  introduction  of  lint,  dipped  in  solution  of  vitriol,  but  this  was 
rather  as  an  astringent  than  a  plug,  and  he  does  not  propose  it  as  a  general  prac- 
tice. He  considers,  that  he  was  obliged  to  have  recourse  ad  anceps  et  extremum 
auxilhan. — Vide  Opera  Omnia,  T.  IV.  Leroux  employed  the  plug  more  freely. 
— Vide  Observations  surles  Pertes,  1776.  Some  modern  writers  hold  it  in  little 
estimation  ;  and  Gardien  says,  that  when  the  placenta  is  attached  over  the  os  uteri- 
it  is  injurious,  by  exciting  the  uterus  to  dilate  the  mouth.    T.  II.  p.  404. 

11 


314 

purpose  which  can  be  expected  from  them  ;  and  whenever  a  dis- 
charge takes  place  to  such  a  degree  as  to  be  called  a  flooding,  or 
lasts  beyond  a  very  short  time,  this  ought  to  be  resorted  to.  The 
advantage  is  so  great  and  speedy,  that  I  am  surprised  that  it  ever 
should  be  neglected.  I  grant  that  some  women  may,  from  deli- 
cacy or  other  motives,  be  averse  from  it;  but  every  consideration 
must  yield  to  that  of  safety  :  and  it  should  be  impressed  deeply  on 
the  mind  of  the  patient,  as  well  as  of  the  practitioner,  that  blood 
is  most  precious,  and  not  a  drop  should  be  spilled  which  can  be 
preserved.  Unless  the  flooding  shall  in  the  first  attack  be  perma- 
nently checked,  which,  when  the  separated  vessels  are  large  or 
numerous,  is  rarely  accomplished,  we  may  expect  one  or  more  re- 
turns before  expulsion  can  be  accomplished.  The  more  blood, 
then,  that  we  allow  to  be  lost  at  first,  the  less  able  shall  the  patient 
be  to  support  the  course  of  the  disease,  and  the  more  unfavourable 
shall  delivery,  when  it  comes  to  be  performed,  prove  to  her  and 
to  the  child.  It  is  of  consequence  to  shorten  the  paroxysm  as 
much  as  possible ;  and  therefore,  when  circumstances  will  permit, 
we  should  make  it  a  rule  to  have  from  the  first  a  careful  nurse, 
who  may  be  instructed  in  our  absence  to  use  the  napkin  without 
delay,  should  the  hemorrhage  return. 

But  whilst  I  so  highly  commend,  and  so  strongly  urge  the  use 
of  the  plug,  I  do  not  wish  to  recommend  it  to  the  neglect  of 
other  means,  or  in  every  situation.  In  the  early  attacks  of  he- 
morrhage, when  the  os  uteri  is  firm,  and  manual  interference  is 
improper,  I  know  of  no  method  more  safe  or  more  effectual  for  re- 
straining the  hemorrhage  and  preserving  the  patient.  But  when 
the  hemorrhage  has  been  profuse,  or  frequently  repeated,  and  the  cir- 
cumstances of  the  patient  demand  more  active  practice,  and  point 
out  the  necessity  of  delivery,  then  the  use  of  the  plug  cannot  be 
proper.  If  trusted  to,  it  may  be  attended  with  fatal  and  deceitful 
effects.  We  can  indeed  restrain  the  hemorrhage  from  appearing 
outwardly  ;  but  there  have  been  instances,  and  these  instances 
ought  to  be  constantly  remembered,  where  the  blood  has  collect- 
ed within  the  uterus,  which,  having  lost  all  power,  has  become  re- 
laxed, and  been  slowly  enlarged  with  coagula ;  the  strength  has 


315 

decreased — the  bowels  become  inflated — the  belly  swelled  beyond 
its  size  in  the  ninth  month,  although  the  patient  may  not  have  been 
near  that  period  ;  and  in  these  circumstances,  whilst  an  inattentive 
practitioner  has  perhaps  concluded  that  all  was  well  with  regard 
to  the  hemorrhage,  the  patient  has  expired,  or  only  lived  long 
enough  to  permit  the  child  to  be  extracted.  All  practical  writers 
warn  us  against  internal  flooding ;  nay,  so  far  do  some  carry  their 
apprehension,  that  they  advise  us  to  raise  the  head  of  the  child,, 
and  observe  whether  blood  or  liquor  amnii  be  discharged  ;*  an  ad- 
vice, however,  to  which  I  cannot  subscribe,  because  in  those  cases 
where  the  membranes  have  given  way,  or  been  opened,  the  head 
cannot  be  thus  moveable,  nor  these  trials  made,  unless  we  have- 
waited  until  a  dangerous  relaxation  has  taken  place  in  the  uterine 
fibres ;  and  if,  on  the  other  hand,  we  have  delivery  in  contempla-= 
tion,  it  is  our  object  to  confine  the  liquor  amnii  as  much  as  possi- 
ble, until  we  turn  the  child.  Blood  may  also  collect  in  the  upper 
part  of  the  vagina,  to  a  dangerous  quantity,  when  the  plug  has  been 
trusted  to,  too  late. 

Besides  using  these  means,  it  will  also,  especially  in  a  first  at- 
tack, and  where  we  have  it  not  in  contemplation  to  deliver  the  wo- 
man, be  proper  to  exhibit  an  opiate,(rfJ  in  order  to  allay  irritation; 
and  this  is  often  attended  with  a  very  happy  effect.  On  this  subject 
long  experience  enables  me  to  speak  with  decision,  and  to  recom- 
mend, in  every  instance  where  the  hemorrhage  does  not  depend 
on  plethora,  the  exhibition  of  a  full  dose  of  laudanum,  which  tran- 
quilises  the  patient,  allays  irritation,  and  checks,  for  the  time,  the. 
discharge. 

Such  are  the  most  effectual  methods  of  speedily  or  immediately 
stopping  the  violeuce  of  the  hemorrhage.  The  next  points  for 
consideration  are,  whether  we  can  expect  to  carry  the  patient 

*  Vide  Dr.  Johnson's  System  of  Midwifery,  p.  157.  and  Dr.  Leake's  Diseases  of 
Women,  Vol.  II.  p.  280. 

(d)  In  the  exhibition  of  opiates  in  uterine  hemorrhagies  generally,  w<» 
would  advise  their  combination  with  ipecacuanha,  in  the  proportion  of  half  a 
grain  of  the  latter  to  about  two  grains  of  opium  ;  to  be  repeated  more  or  less 
frequently,  according  to  the  circumstances  of  the  case.  Vide  Barton's  Edit,  -of 
Oullen's  Mat.  Med.  Vnl.ii.  p.  334,  and  Chapman's  Edit,  of  Burns'. 


516 


Vaiely  to  the  full  time,  and  by  what  means  \vc  are  to  prevent  a  re- 
newal of  the  discharge. 

It  may,  I  believe,  be  laid  down  as  a  general  rule,  that  when  a 
considerable  portion  of  the  decidua  has  in  the  seventh  month,  or 
later,  been  separated,  the  hemorrhage,  although  it  may  be  checked, 
is  apt  to  return.  When  a  part  of  the  placenta  has  been  detached, 
and  more  especially  if  that  organ  be  fixed  over  the  os  uteri,  ges- 
tation cannot  continue  long;  for  either  such  injury  is  done  to  the 
uterus  as  produces  expulsion  and  a  natural  cure,  or  the  woman 
bleeds  to  death,  or  we  must  deliver,  in  order  to  prevent  that  dread- 
ful termination. 

If  the  discharge  be  in  small  quantity,  and  have  not  flowed  with 
much  rapidity — if  it  stop  soon  or  easily — if  no  large  clots  are 
formed  in  the  vagina — if  the  under  part  of  the  uterus  has  its  usual 
feel,  showing  that  the  placenta  is  not  attached  there,  and  that  no 
large  coagula  are  retained  within  the  os  uteri — if  the  child  be  still 
alive — if  there  be  no  indication  of  the  accession  of  labour — and  if 
the  slight  discharge  which  is  still  coming  away  be  chiefly  watery, 
we  may,  in  these  circumstances,  conclude,  that  the  vessels  which 
have  given  way  are  not  very  large,  and  have  some  reason  to  ex- 
pect, that  by  care  and  prudent  conduct,  the  full  period  of  gestation 
may  be  accomplished.  It  is  difficult  to  say,  whether,  in  this  event 
the  uterus  forms  new  vessels  to  supply  the  place  of  those  which 
have  been  torn,  and  whether  re-union  be  effected  by  the  incorpo- 
ration of  those  with  corresponding  vessels  from  the  chorion.  In 
the  early  months  we  know  that  re-union  may  take  place;  but 
when,  in  the  advanced  period  of  pregnancy,  the  decidua  has  be- 
come very  thin,  soft,  and  almost  gelatinous,  it  is  not  established 
that  the  circulation  may  be  renewed.  At  all  events,  we  know  that 
the  power  of  recovery  or  reparation  is  very  limited,  and  can  only 
be  exerted  when  the  injury  is  not  extensive.  The  means  for  pro- 
moting re-union  of  the  uterus  and  decidua,  are  the  same  with  those 
which  we  employ  for  preventing  a  return  of  the  hemorrhage ;  and 
these  we  advise,  even  when  we  have  little  hope  of  effecting  re- 
union, and  making  the  patient  go  to  the  full  time,  because  it  is  our 
object  to  prevent,  asjnuch  as  possible,  the  loss  of  blood. 


31? 

When  the  placenta  is  partly  separated,  all  the  facts  of  which  we 
are  in  possession,  are  against  the  opinion  that  re-union  can  take 
place.  If  the  spot  be  very  trifling,  and  the  vessels  not  large,  we 
may  have  no  return  of  the  bleeding ;  a  small  coagulum  may  per- 
manently restrain  it ;  but  if  the  separation  be  greater,  and  the  pla- 
centa attached  low  down,  or  over  the  os  uteri,  the  patient  cannot 
go  to  the  full  time,  unless  that  be  very  near  its  completion.  We 
judge  of  the  case  by  the  profusion  and  violence  of  the  discharge ; 
for  all  great  hemorrhages  proceed  from  the  separation  of  the  pla- 
centa; and  by  the  feel  of  the  lower  part  of  the  uterus, — by  the 
quantity  of  clots,  and  the  obstinacy  of  the  discharge,  which  may 
perhaps  require  even  actual  syncope  to  stop  the  paroxysm ;  a  cir- 
cumstance indicating  great  danger. 

The  best  way  by  which  we  can  prevent  a  return,  is  to  moderate 
the  circulation,  and  keep  down  the  actions  of  the  system  to  a  pro- 
per level  with  the  power.  The  propriety  of  attending  to  this  rule 
will  appear,  if  we  consider,  among  other  circumstances,  that  when 
a  patient  has  had  an  attack  of  flooding,  a  surprise,  or  any  agitation 
which  can  give  a  temporary  acceleration  to  the  circulation,  wiil 
often  renew  the  discharge.  The  action  of  the  arteries  depends 
very  much  upon  that  of  the  heart ;  and  the  action  of  this  organ 
again  is  dependent  on  the  blood.  When  much  blood  is  lost,  the 
heart  is  feebly  excited  to  contraction,  and  in  some  cases  it  beats 
with  no  more  force  than  is  barely  sufficient  to  empty  itself.  This 
evidently  lessens  the  risk  of  a  renewal  of  the  bleeding ;  and  in. 
several  cases,  as,  for  example,  in  hemoptysis,  we,  by  suddenly 
detracting  a  quantity  of  blood,  speedily  excite  this  state  of  the 
heart.  Whatever  tends  to  rouse  the  action  of  the  heart,  tends  to 
renew  hemorrhage  ;  and  if  the  proposition  be  established,  that  the 
rapidity  with  which  the  strength  and  action  of  the  vessels  are  di- 
minished is  much  influenced  by  the  rapidity  with  which  a 
stimulus  is  withdrawn,  the  converse  is  also  true ;  and  we  should 
find,  were  it  practicable  to  restore  the  quantity  of  blood  as 
quickly  as  it  has  been  taken  away,  that  the  same  effect  would 
be  produced  on  the  action  of  the  heart,  as  if  a  person  had 
taken  a  liberal  dose  of  wine.  It  has  been  the  practice  to  give 
Hourishiug  die;  to  restore  the  quantity  of  blood;  but  until  the  run- 


318 

tured  vessels  be  closed,  or  the  tendency  to  hemorrhage  stopped, 
this  must  be  hurtful.  It  is  our  anxious  wish  to  prevent  the  loss  of 
blood;  but  it  does  not  thence  follow,  that,  when  it  is  lost,  we 
should  wish  rapidly  to  restore  it.  This  is  against  every  principle 
of  sound  pathology;  but  it  is  supported  by  the  prejudices  of  those 
who  do  not  reflect,  or  who  are  ignorant  of  the  matter.  When 
a  person  is  reduced  by  flooding,  even  to  a  slight  degree,  taking 
much  food  into  the  stomach,  gives  considerable  irritation ;  and  if 
much  blood  be  made,  vascular  action  must  be  increased.  What 
is  it  which  stops  the  flow  of  blood,  or  prevents  for  a  time  its  repe- 
tition ?  Is  it  not  diminished  force  of  the  circulation  which  cannot 
overcome  the  resistance  given  by  the  coagula  ?  Does  not  motion 
displace  these  coagula,  and  renew  the  bleeding?  Does  not  wine 
increase  for  a  time  the  force  of  the  circulation,  and  again  excite 
hemorrhage?  Is  it  not  conformable  to  every  just  reasoning,  and  to 
die  experience  of  ages,  that  full  diet  is  dangerous  when  vessels  are 
opened?  Do  we  not  prohibit  nourishing  food  and  much  speaking 
in  hemorrhage  from  the  lungs?  And  can  nourishing  diet  and  motion 
be  proper  in  hemorrhage  from  the  uterus?  If  it  were  possible  to 
restore  in  one  hour  the  blood  which  has  been  lost  in  a  paroxysm 
of  flooding,  it  is  evident,  that,  unless  the  local  condition  of  the 
parts  were  altered,  the  flooding  would,  at  the  end  of  that  hour,  be 
renewed.  » 

The  diet  should  be  light,  mild,  given  in  small  quantity  at  a  time, 
so  as  to  produce  little  irritation;*  and  much  fluid,  which  would  soon 
fill  the  vessels,  should  be  avoided.  We  shall  do  more  good  by 
avoiding  every  thing  which  can  stimulate  and  raise  action,f  than 

*  Such  as  animal  jellies,  sago,  toasted  bread,  hard  biscuit,  Sec.  These  articles,, 
given  at  proper  intervals,  are  sufficient  to  support  the  system  without  raising  the 
action  too  much. 

|  The  system,  with  its  power  of  action,  may,  for  illustration,  be  compared  to  a 
man  with  his  income.  He  who  had  formerly  two  hundred  pounds  per  annum, 
but  has  now  only  one,  must,  in  order  to  avoid  bankruptcy,  spend  only  one  half  of 
what  he  did  before ;  and  if  he  do  so,  although  he  has  been  obliged  to  live  lower,, 
yet  his  accounts  will  be  square  at  the  end  of  the  year. — The  same  applies  to  the 
system.  When  its  power  is  reduced,  the  degree  of  its  action  must  also  be  re- 
duced; andj  by  carefully  proportioning  the  one  to  the  other,  we  may  often  cob- 


319 

by  replenishing  the  system  rapidly,  and  throwing  rich  nutriment 
into  the  stomach. 

It  is,  however,  by  no  means  my  intention  to  say,  that  we  must, 
during  the  whole  remaining  course  of  gestation,  (provided  that  that 
go  on,  the  attack  having  been  permanently  cured)  keep  down  the 
quantity  of  blood.  I  only  mean  that  we  are  not  rapidly  to  increase 
it.  Even  where  the  strength  has  been  much  impaired  by  the  pro* 
fusion  of  the  discharge,  or  the  previous  state  of  the  system,  it  is 
rather  by  giving  food  so  as  to  prevent  further  sinking,  than  by  cram- 
ming the  patient,  that  we  promote  recovery;  and  I  beg  it  to  be  re- 
membered, that  although  I  talk  of  the  management  of  those  who 
are  much  reduced,  yet  I  am  not  to  be  understood  as  in  any  degree 
encouraging  the  practice  of  delay,  and  allowing  the  patient  to  come 
into  this  situation  of  debility ;  but  when  we  find  her  already  in  this 
state,  it  is  not  by  pouring  cordials  and  nutriment  profusely  into  the 
stomach,  that  we  are  to  save  her ;  it  is  by  giving  mild  food,  so  as 
gradually  to  restore  the  quantity  of  blood  and  the  strength ;  it  is 
by  avoiding  the  stimulating  plan  on  the  one  hand,  and  the  starving 
system  on  the  other,  that  we  are  to  carry  her  safely  through  the 
danger. 

Some  medicines  possess  a  great  power  over  the  blood  vessels, 
and  enable  us,  in  hemorrhage,  to  cure  our  patient  with  less  ex- 
pense of  blood  than  we  could  otherwise  do.  Digitalis  is  of  this 
class,  and  may  be  given  for  a  short  time,  with  advantage,  in  flood- 
ing, where  the  pulse  indicates  increased  vascular  action,  and  when 
we  do  not  mean  to  proceed  directly  to  delivery.  But  when  the 
discharge  has  been  trifling,  and  the  pulse  is  slow,  and  perhaps  fee- 
ble, digitalis  is  unnecessary  even  from  the  first,  or  may  be  hurtful; 
and  if,  in  the  progress  of  the  disease,  the  stomach  have  become 

tluct  a  patient  through  a  very  great  and  continued  degree  of  feebleness.  At  the 
same  time,  it  must  be  observed,  that  as  there  is  an  income  so  small  as  not  to  be 
sufficient  to  procure  the  necessaries  of  life,  so  also  may  the  vital  energy  be  so 
much  reduced,  as  to  be  inadequate  to  the  performance  of  those  actions  which  are 
essential  to  our  existence,  and  death  is  the  result.  But  surely  he  who  should  at- 
tempt to  prevent  this  by  stimulating  the  system,  would  only  hasten  the  fatal  ter- 
mination. Does  not  heat  overpower  and  destroy  those  parts  which  have  been 
frost- bit  ? 


320 

effected,  and  the  patient  is  sick,  inclined  to  vomit,  or  faintish,  or 
the  pulse  feeble  and  small,  it  is  likewise  improper. 

In  those  cases  which  demand  it,  when  the  pulse  is  sharp,  and 
throbbing,  and  frequent,  it  may  be  given  in  the  form  of  tincture. 
Two  drachms  may  be  added  to  a  four-ounce  mixture,  and  a  table- 
spoonful  given  every  two  hours,  watching  the  effect,  and  diminish- 
ing the  dose  when  necessary.  It  ought  seldom  to  be  continued 
above  two  days,  and  sometimes  all  the  benefit  to  be  expected  from 
it  is  derived  in  twenty-four  hours. (e) 

At  the  same  time  that  we  thus  endeavour  to  diminish  the  action 
of  the  vascular  system,  we  must  also  be  careful  to  remove,  as  far 
as  we  can,  every  irritation.  I  have  already  said  all  that  is  neces- 
sary with  regard  to  heat,  motion,  and  diet.  The  intestinal  canal 
must  also  be  attended  to,  and  accumulation  within  it  should  be 
carefully  prevented  by  the  regular  exhibition  of  laxatives.  A  cos- 
tive state  is  generally  attended  with  a  slow  circulation  in  the  veins 
belonging  to  the  hepatic  system,  and  of  these  the  uterine  sinuses 
form  a  part.     If  the  arterial  system  be  not  proportionally  checked, 

(e)  Our  author  has  here  omitted  to  mention,  the  powerful  effects  of  the  ace- 
tate of  lead  in  restraining  uterine  hemorrhage. 

The  dose  must  depend  upon  the  circumstances  of  the  case,  and  the  judgment 
of  the  practitioner.  In  a  general  way  we  may  say,  that  two  or  three  grains  may 
be  given  at^a  time,  and  repeated  more  or  less  frequently  according  to  the  ur- 
gency of  the  symptoms.     It  should  be  combined  with  a  portion  of  opium. 

Professor  Barton,  who  has  called  the  attention  of  American  practitioners  to 
this  powerful  article  of  the  materia  medica  in  restraining  internal  hemorrhage, 
recommends  the  combining  with  it  a  portion  of  ipecacuanha.  For  his  opinion  on 
this  subject,  we  must  refer  the  student  to  the  Professor's  edition  of  Cullen's 
Materia  Medica,  vol.  ii.  p.  20,  21,  and  334.  Other  practitioners,  among  whom  is 
Dr.  Chapman,  in  these  cases  place  considerable  confidence  in  a  combination  of 
opium  and  ipecacuanha,  in  the  proportion  of  two  grains  of  the  former  to  half  a 
grain  of  the  latter,  to  be  repeated  every  two  hours. 

From  my  own  experience,  I  should  be  induced  to  decide  in  favour  of  the  ace- 
tate of  lead,  when  combined  as  above  directed. 

Dr.  Kuhn  informed  mc  that  the  late  Dr.  Glentworth  of  this  city,  placed  the 
greatest  reliance  on  yarrow-tea,  or  a  strong  decoction  of  yarrow  (Achillea  Mille- 
folium, L.)  in  uterine  hemorrhage,  and  said  that  he  never  was  disappointed  in 
his  expectations  of  a  cure  after  the  proper  use  of  this  article  of  the  materia  medica. 
Instances  of  its  good  effects  in  hemorrhagies  are  mentioned  by  several  of  the 
German  physicians,  particularly  by  Stahl  and  Hoffman. 


321 

this  sluggish  motion  is  apt,  by  retarding  the  free  transmission  along 
the  meseraic  veins,  to  excite  the  hemorrhage  again. 

Uneasiness  about  the  bladder  or  rectum,  or  even  in  more  distant 
parts,  should  be  immediately  checked ;  for  in  many  cases  hemor- 
rhage is  renewed  by  these  irritations.  In  those  cases,  or  where  the 
patient  is  troubled  with  cough,  or  affected  with  palpitation,  or  an 
liysterical  state,  much  advantage  may  be  derived  from  the  exhibi- 
tion of  opiates.  In  many  instances,  where  an  attack  of  flooding  is 
brought  on  by  some  irritation  affecting  the  lower  part  of  the  uterus 
in  particular,  or  the  system  in  general,  or  where  the  bowels  are 
pained,  and  the  pulse  not  full  nor  strong,  rest,  cool  air,  and  an  ade- 
quate dose  of  tincture  of  opium  will  terminate  the  paroxysm,  and 
perhaps  prevent  a  return.  This  is  especially  the  case,  if  only  a  part 
of  the  decidua  have  been  separated,  and  the  discharge  have  not 
been  profuse.  When  the  vascular  system  is  full,  venesection  is  ne- 
cessary before  the  anodyne  be  administered,  and  die  digitalis  may 
-either  succeed  the  opiate  or  be  omitted,  according  to  the  state  of 
the  pulse  and  of  the  stomach. 

It  may  happen  that  we  have  not  been  called  early  in  a  first  at- 
tack, and  that  some  urgent  symptom  has  appeared.  The  most  fre- 
quent of  these,  is  a  feeling  of  faintness  or  complete  syncope.  This 
feeling  often  arises  ratlier  from  an  affection  of  the  stomach  than 
from  absolute  loss  of  blood;  and  in  this  case  it  is  less  alarming  than 
when  it  follows  copious  hemorrhage.  In  either  case,  however,  we 
must  not  be  too  hasty  in  exhibiting  cordials.  When  the  faintish- 
ness  depends  chiefly  upon  sickness  at  the  stomach,  or  feeling  of 
failure,  circumstances  which  may  accompany  even  a  small  discharge, 
it  will  be  sufficient  to  give  a  few  drops  of  hartshorn  in  cold  water? 
and  sprinkle  the  face  with  cold  water :  a  return  is  prevented  by  an 
anodyne  draught,  or  opium  pill.  When  it  is  more  dependent  on 
absolute  loss  of  blood,  we  may  find  it  necessary  to  give  a  full  dose 
of  opium  or  laudanum,  with  the  addition  of  small  quantities  of  wine 
warmed  with  aromatics;  but  the  latter,  even  in  this  case,  must  not 
be  given  with  a  liberal  hand,  nor  too  frequently  repeated.*     It  i.s 

*  As  syncope  and  loss  of  blood  have  both  the  effect  of  relaxing  the  muscular 
fibre,  as  is  well  known  to  surgeons,  it  may  be  supposed  that  they  sbould  increase 

4^ 


322 

scarcely  necessary  for  me  to  add,  that  We  are  also  to  take  immediate 
steps,  by  the  use  of  the  plug,  &c.  for  restraining  the  discharge. 
This  I  may  observe  once  for  a\L(f) 

Complete  syncope  is  extremely  alarming  to  the  bye-standers : 
and,  if  there  have  been  a  great  loss  of  blood,  it  is  indeed  a  most 
dangerous  symptom.  It  must  at  all  times  be  relieved,  for  although 
faintness  be  a  natural  mean  of  checking  hemorrhage,  yet  absolute 
and  prolonged  syncope  is  hazardous.  We  must  keep  the  patient 
at  perfect  rest,  in  a  horizontal  posture,  with  the  head  low,  open  the 
windows,  sprinkle  the  face  smartly  with  cold  vinegar,  apply  volatile 
salts  to  the  nostrils,  and  give  sixty  or  eighty  drops  of  laudanum  in- 
ternally, and  occasionally  a  spoonful  of  warm  wine. 

Universal  coldness  is  also  a  symptom  which  must  not  be  allowed 
to  go  beyond  a  certain  degree,  and  this  degree  must  be  greatly  de- 
termined by  the  strength  of  the  patient,  and  the  quantity  and  rapi- 
dity of  the  discharge.  When  the  strength  is  not  previously  much 
reduced,  a  moderate  degree  of  coldness  is,  if  the  hemorrhage 
threaten  to  continue,  of  service ;  but  when  there  has  been  a  great 
loss  of  blood,  then  universal  coldness,  with  pale  lips,  sunk  eyes, 
and  approaching  deliquium,  may  too  often  be  considered  as  a  fore- 
runner of  death.  When  we  judge  it  necessary  to  interfere,  we 
should  apply  warm  cloths  to  the  hands  and  feet,  a  bladder  half 
filled  with  tepid  water  to  the  stomach,  and  give  some  hot  wine  and 
water  inwardly. 

Vomiting  is  another  symptom  which  sometimes  appears.  It 
proceeds  very  generally  from  the  attendants  having  given  more 

the  flooding  by  diminishing  the  contraction  of  the  uterus,  if  that  have  already 
taken  place.  But  the  contrary  is  the  case,  for  by  allowing  coagula  to  form,  syn- 
cope restrains  hemorrhage,  and  therefore  ought  not  to  be  too  rapidly  remov- 
ed, in  a  first  attack,  and  before  the  os  uteri  has  become  dilatable. 

C/J  In  restraining  uterine  hemorrhage,  we  should  not  forget  that  injections, 
thrown  up  the  vagina,  and  if  possible  into  the  uterus,  may  have  a  considerable 
effect  in  repressing  the  discharge.  In  this  way  1  have  known  solutions  of  the  ace- 
tate of  lead,  of  the  sulphate  of  alumine,  and  a  strong  decoction  or  infusion  of 
galls,  produce  salutary  effects.  A  solution  of  the  acetate  of  lead  in  cold  water, 
combined  with  laudanum,  may  also  be  thrown  up  by  enema,  as  recommended  by 
Dr.  Dewces. 


323 

nourishment  or  fluid  than  the  stomach  can  bear,  or  from  a  gush  of 
blood  taking  place  soon  after  the  patient  has  had  a  drink.  It  in 
this  case  is  commonly  preceded  by  sickness  and  oppression,  which 
arc  most  distressing,  and  threaten  syncope,  until  relief  is  obtained 
by  vomiting.  Sometimes  it  is  rather  connected  with  an  hysterical 
state,  or  with  uterine  irritation.  If  frequently  repeated,  it  is  a  de- 
bilitating operation,  and  by  displacing  clots  may  renew  hemorrhage ; 
but  sometimes  it  seems  fortunately  to  excite  the  contraction  of  the 
-uterus,  and  gives  it  a  disposition  to  empty  itself.  For  abating 
vomiting,  we  may  apply  a  cloth  dipped  in  laudanum,  and  cam- 
phorated spirits  of  wine,  to  the  whole  epigastric  region ;  or  give 
two  grains  of  solid  opium,  or  even  more,  if  the  weakness  be  great. 
Sometimes  a  little  infusion  of  capsicum  is  of  service.  It  should 
just  be  gently  pungent.  In  flooding  it  is  of  importance  to  pay 
much  attention  to  the  state  of  the  stomach,  and  prevent  it  from 
being  loaded ;  on  the  other  hand,  we  must  not  let  it  remain  too 
empty,  nor  allow  its  action  to  sink.  Small  quantities  of  pleasant 
nourishment  should  be  given  frequently.  We  thus  prevent  it  from 
losing  its  tone,  without  oppressing  it,  or  filling  the  system  too  fast. 

Hysterical  affections  often  accompany  protracted  floodings,  such 
as  globus,  pain  in  the  head,  feeling  of  suffocation,  palpitation," 
retching,  in  which  nothing  but  wind  is  got  up,  he.  These  are 
best  relieved  by  some  foetid  or  carminative  substance  conjoined 
with  opium.  The  retching  sometimes  requires  an  anodyne  clys- 
ter, or  the  application  of  a  camphorated  plasterf  to  the  region  of 
the  stomach. 

After  having  made  these  observations  on  the  management  of 
flooding,  and  the  best  means  of  moderating  its  violence,  of  pre- 
venting a  return,  and  of  relieving  those  dangerous  symptoms  which 

*  The  quantity  of  blood  lost  is  sometimes  so  great  as  to  do  irreparable  injury 
to  the  heart,  and  ever  after  to  impede  its  action.  One  well  marked  instance  of 
this  is  related  by  Van  Swieten,  in  his  commentary  on  Aph.  1304,  where  for 
twelve  years  the  woman,  after  a  severe  flooding,  could  not  sit  up  ia  bed  without 
violent  palpitation  and  anxiety. 

f  This  may  be  made  by  melting  a  little  adhesive  plaster,  and  then  adding  to 
A  a  large  proportion  of  camphor,  previously  made  into  a  thick  liniment  by  rub- 
bing it  with  olive  oil. 


324 

sometimes  attend  it,  I  next  proceed  to  speak  of  the  method  of  de- 
livering the  patient  when  that  is  necessary.  I  have  separated  the 
detail  of  the  medical  treatment  of  a  paroxysm  from  the  considera- 
tion of  the  manual  assistance,  which  may  be  required;  because, 
however  intimately  connected  the  different  parts  of  our  plan  may 
be,  in  actual  practice,  it  is  useful,  in  a  work  of  this  kind,  in  order 
to  avoid  confusion,  that  I  lay  them  down  apart. 

As  some  peculiarities  of  practice  arise  from  the  implantation  of 
the  placenta  over  the  os  uteri,  I  shall  confine  my  present  remarks 
to  those  cases  in  which  the  membranes  are  found  at  the  mouth  of 
the  womb,  desiring  it  to  be  remembered,  however,  that  this  cir- 
cumstance does  not  necessarily  indicate  that  the  hemorrhage  does 
not  proceed  from  separation  of  the  placenta,  which  may  be  fixed 
very  near  the  cervix,  although  it  cannot  be  felt. 

The  operation  of  delivering  the  child  is  not  difficult  to  describe 
Or  to  perform.  I  am  generally  in  the  practice  of  giving,  a  quarter 
of  an  hour  before  I  begin,  fifty  drops  of  tincture  of  opium,  or  if  the 
patient  be  much  reduced,  I  give  even  eighty.  The  hand,  pre- 
viously lubricated,  is  then  to  be  slowly  and  gently  introduced  com- 
pletely into  the  vagina.  The  finger  is  to  be  introduced  into  the 
os  uteri,  and  cautiously  moved  so  as  to  dilate  it:  or  if  it  has  al- 
ready dilated  a  little  more,  two  fingers  may  be  inserted,  and  very 
slow  and  gentle  attempts  made  at  short  intervals  to  distend  it;  and 
the  practitioner  will  do  well  to  remember,  that  he  will  succeed 
best  when  he  rather  acts  so  as  to  stimulate  the  uterus  and  make  it 
dilate  its  mouth,  than  forcibly  to  distend  it.  On  the  part  of  the 
operator,  is  demanded  much  tenderness,  caution,  firmness,  and 
composure ;  on  the  part  of  the  patient  is  to  be  desired  patience 
and  resolution.  The  operator  is  to  keep  in  mind,  that  painful  di- 
lation is  dangerous,  it  irritates  and  inflames  the  parts,  and  that  the 
woman  should  complain  rather  of  the  uterine  pains  which  are  ex- 
cited, than  of  the  fingers  of  the  practitioner.  More  or  less  time 
will  be  required  fully  to  dilate  the  os  uteri,  according  to  the  state 
in  which  the  uterus  was  when  the  operation  was  begun.  If  the 
os  uteri  is  soft  and  pliable,  and  has  already,  by  slight  pains,  been 
in  part  distended,  a  quarter  of  an  hour,  or  perhaps  only  a  few 
•minutes,  will  often  be  sufficient  for  this  purpose ;  but  if  it  has 


826 

scarcely  been  affected  before  by  pains,  and  is  pretty  firm,  though 
not  unyielding,  then  half  an  hour  may  be  required.  I  speak  in 
general  terms,  for  no  rule  can  be  given  applicable  to  every  case. 
Not  unfrequently,  although  the  patient  have  felt  scarcely  any 
pains,  and  certainly  no  regular  pains,  the  os  uteri  will  be  found  as 
large  as  a  penny  piece,  and  its  margin  soft  and  thin.  The  os  uteri 
being  sufficiently  dilated,  the  membranes  are  to  be  ruptured,  the 
hand  introduced,  the  child  slowly  turned  and  delivered,  as  in  foot- 
ling cases  j  endeavouring  rather  to  have  the  child  expelled  by 
uterine  contraction  than  brought  away  by  the  hand.  Hasty  ex- 
traction is  dangerous,  for  the  uterus  will  not  contract  after  it.  And, 
therefore,  if  when  we  are  turning,  we  do  not  feel  the  uterus  acting, 
we  must  move  the  hand  a  little,  and  not  begin  to  deliver  until  we 
perceive  that  the  womb  is  contracting.  The  delivery  must  be 
but  slow  until  the  breech  is  passing  ;  then  we  must  be  careful  that 
the  cord  be  not  too  long  compressed  before  the  rest  of  the  child 
be  born.  The  child  being  removed,  and  the  belly  properly  sup- 
ported, and  gently  pressed  on  by  an  assistant,  the  hand  should 
again  be  cautiously  introduced  into  the  womb,  and  the  two 
knuckles  placed  on  the  surface  of  the  placenta,  so  as  to  press  it  a 
little,  and  excite  the  uterus  to  separate  it.  The  hand  may  also  be 
gently  moved  in  a  little  time,  and  the  motion  repeated  at  intervals, 
so  as  to  excite  the  uterus  to  expel  its  contents;  but  upon  no  ac- 
count are  we  to  separate  the  placenta  and  extract  it.  This  must 
be  done  by  the  uterus :  for  we  have  no  other  sign  that  the  con- 
traction will  be  sufficient  to  save  the  woman  from  future  hemor- 
rhage. The  whole  process,  from  first  to  last,  must  be  slow  and 
deliberate,  and  we  are  never  to  lose  sight  of  our  object,  which  is 
to  excite  the  expulsive  power  of  the  uterus.  It  is  not  merely  to 
empty  the  uterus — it  is  not  merely  to  deliver  the  child,  that  we 
introduce  our  hand:  all  this  we  may  do,  and  leave  the  woman 
worse  than  if  we  had  done  nothing.  The  fibres  must  contract  and 
press  upon  the  vessels ;  and  as  nothing  else  can  save  the  patient, 
it  is  essential  that  the  practitioner  have  clear  ideas  of  his  object, 
and  be  convinced  on  what  the  security  of  the  patient  depends. 

But  to  teach  the  method  of  delivery,  and  say  nothing  of  the  cir- 
cumstances under  which  it-is  to  be  performed,  would  be  a  most 


dangerous  error.  I  have,  in  the  beginning  of  tkis  section,  pointed 
oat  the  effect  of  hemorrhage,  both  on  the  constitution  and  on  the 
uterus :  and  I  have  stated,  that  the  action  of  sestation  is  always  im- 
paired by  a  certain  loss  of  blood,  and  a  tendency  to  expulsion 
brought  on.  But  before  the  uterine  contraction  can  be  fullv  ex- 
cited, or  become  effective,  the  woman  may  perish,  or  the  uterus 
be  so  enfeebled  as  to  render  expulsion  impossible.  Whilst  then 
we  look  upon  the  one  hand  to  the  induction  of  contraction,  we 
must  not  on  the  other  delay  too  Ions.  We  must  not  witness  many 
and  repeated  attacks  of  hemorrhage,  sinkins  the  strength,  bleach- 
ing the  lips  and  tongue,  producing  repeated  fainting  fits,  and  bring- 

-  .iie  itself  into  immediate  danger.  Such  delav  is  most  inexcu- 
sable and  dangerous  ;  it  may  end  in  the  sudden  loss  of  mother  and 
child ;  it  may  enfeeble  the  uterus,  and  render  it  unable  afterwards 
to  contract :  or  it  may  so  ruin  the  constitution,  as  to  bring  the  pa- 
tient, after  a  long  train  of  sufferings,  to  the  srave. 

we  then  uniformly  to  deliver  upon  the  first  attack  of  flood- 
ing, and  forcibly  open  the  os  uteri  ?  By  no  means  :  safety  is  not 
to  be  found  either  in  rashness  or  procrastination. 

The  treatment  which  I  have  pointed  out,  will  always  secure  the 
patient  until  the  delivery  can  be  safely  accomplished.  As  lo:  t 
the  os  uteri  is  firm  and  unyielding — as  long  as  there  is  no  tenden- 
cy to  open,  no  attempt  to  establish  contraction,  it  is  perfectly  safe 
to  trust  to  the  plus,  rest,  and  cold.  But  I  must  particularly 
to  the  reader,  that  the  os  uteri  may  dilate  without  regular  pains  ; 
and  in  almost  every  instance  it  does,  whether  there  be  or  be  not 
pains,  become  dilatable.  Did  I  not  know  the  danger  of  establish- 
ing positive  rules,  I  would  say,  that  as  long  as  the  os  uteri  is  firm, 
and  has  no  disposition  to  open,  the  patient  can  be  in  little  risk, 
if  we  understand  the  use  of  the  plug  ;  we  may  even  plug  the  os 
uteri  itself,  which  will  excite  contraction.     But  if  the  patient  be 

..ected,  then  I  grant  that  Ions  before  a  tendency  to  labour  or 
contraction  be  induced,  she  may  perish.     I  am  not,  however,  con- 
sidering what  may  happen  in  the  hands  of  a  negligent  practitioner, 
for  of  this  there  would  be  no  end,  but  what  ought  to  be  the  resul* 
isence  and  care. 


327 

Ii  is  evident,  that  when  the  uterus  has  a  disposition  to  comic  -. 
and  the  os  uteri  to  open,  delivery  must  be  much  safer  and  ea. 
than  when  it  is  still  inert,  and  the  os  uteri  hard. 

We  may,  with  confidence,  trust  to  the  plug,  until  these  desirable 
effects  be  produced ;  and  in  some  instances,  we  shall  find,  that  by 
the  plug  alone  we  may  secure  the  patient :  the  contraction  may 
become  brisk,  if  we  have  prevented  much  loss  of  blood,  and  ex- 
tern may  naturally  take  place.  Who  would,  in  those  circum- 
stances, propose  to  turn  the  child,  and  deliver  it  r  Who  would  not 
prefer  the  operation  of  nature  to  that  of  the  accoucheur  ?  To  de- 
termine in  any  individual  case  whether  this  shall  take  place,  or 
whether  deliver}*  must  be  resorted  to,  will  require  deliberation  on 
the  part  of  the  practitioner.  If  he  have  used  the  plug  early  and 
effectually,  and  the  pains  have  become  brisk,  he  has  good  reason 
to  expect  natural  expulsion ;  and  the  labour  must  be  conducted  on 
the  general  principles  of  midwifery.  Bui  if  the  uterus  have  been 
enfeebled  by  loss  of  blood — if  the  pains  are  indefinite — if  they 
have  done  little  more  than  just  open  the  os  uteri,  and  have  no  dis- 
position to  increase,  then  he  is  not  justified  in  expecting  that  ex- 
pulsion shall  be  naturally  and  safely  accomplished,  and  he  ought  to 
deliver.  Wfaep  he  dilates  the  os  uteri,  he  excites  the  uterine  ac- 
tion, and  feels  the  membranes  become  tense.  But  he  must  not 
trust  to  this,  he  must  finish  what  he  has  begun. 

Thus  it  appears,  that  by  the  early  and  effective  use  of  the  plug, 
filing  the  vagina  with  a  soft  napkin,  or  with  tow,  we  may  safely 
and  readily  restrain  the  hemorrhage,  until  such  changes  have  taken 
place  on  the  os  uteri  as  to  render  delivery  easy  ;  and  then  we 
ther  interfere  or  trust  to  natural  expulsion,  according  to  the  brisk- 
and  force  of  tne  contraction,  and  state-  of  the  patient. 
By  this  treatment,  we  obtain  ail  the  advantage  that  can  b©  de- 
rived from  the  operations  of  nature ;  and,  where  these  fail,  are 
enabled  to  look  with  confidence  to  the  aid  of  artificial  deli  • 

But  it  may  happen  that  we  have  not  had  an  opportunity  of  re- 
straining the  hemorrhage  early  ;  we  may  not  have  seen  the  patient 
until  she  has  suffered  much  from  the  bleeding.*  In  this  case,  we  shall 

MTe  ire  i  5  ae  our  attention  to  the  quantity  which  has  beea  lost,  but 


328 

generally  be  obliged  to  deliver,  and  must,  upon  no  account,  delay 
too  long  ;  yet,  if  the  os  uteri  be  very  firm,  without  disposition  to 
open,  and  require  hazardous  force  to  dilate  it,  we  shall  generally 
find  that  the  sinking  is  temporary :  we  may  still  trust  for  some 
time  to  the  plug,  and  give  opiates  to  support  strength. 

Hemorrhage  is  naturally  restrained  by  faintness.  A  repetition 
is  checked  in  the  same  way ;  and  faintness  takes  place  sooner  than 
formerly.  In  one  or  two  attacks,  the  uterus  suffers,  and  the  os 
uteri  becomes  dilatable.  Slight  pains  come  on,  or  are  readily  ex- 
cited by  attempts  to  distend  the  os  uteri.  Syncope  then  will,  in 
general,  even  when  the  plug  has  not  been  used,  and  the  patient 
has  been  neglected,  restrain  hemorrhage,  and  prevent  it  from  prov- 
ing fatal  until  the  os  uteri  has  relaxed ;  but  a  little  delay  beyond 
that  period  will  destroy  the  patient ;  and  it  is  possible,  by  giving 
wine,  and  otherwise  treating  her  injudiciously,  to  make  hemor- 
rhage prove  fata],  even  before  this  takes  place.  But  although  I 
have  considered  it  as  a  general  rule,  that  where  the  os  uteri  is  firm 
and  unyielding,  we  may,  notwithstanding  present  alarm,  trust  some 
time  to  the  plug,  yet  I  beg  it  to  be  remembered,  that  there  may 
be  exceptions  to  this  rule ;  for  the  constitution  may  be  so  delicate, 
and  the  hemorrhage  so  sudden,  or  so  much  increased  by  stimu- 
lants, as  to  induce  a  permanent  effect,  and  make  it  highly  desira- 
ble that  delivery  should  be  accomplished :  but  such  instances  are 
rare ;  and  although  I  have  spoken  of  the  effects  of  syncope  in  re- 
straining hemorrhage,  I  hope  it  will  not  be  imagined  by  the  stu* 
dent  that  I  wish  to  make  him  familiar  with  this  symptom.  It  is 
very  seldom  safe,  when  we  have  our  choice,  to  wait  till  syncope 
be  induced ;  and  if  it  have  occurred,  it  is  not  usually  prudent  to 
run  the  risk  of  a  second  attack. 

The  old  practitioners,  not  aware  of  the  value  of  the  plug,  nor 
acquainted  with  the  sound  principles  of  physiology,  had  no  fixed 
rule  relating  to  delivery,  but  endeavoured  to  empty  the  uterus  ear- 
}y ;  but  it  was  uniformly  a  remark,  that  those  women  died  who 

<fo  the  effect  it  has  produced ;  and  this  will  ceteris  paribus  be  great  in  proportion, 
■as  the  hemorrhage  has  been  sudden. 


329 

had  the  os  uteri  firm  and  hard.*  What  is  this  but  to  declare,  that  the 
rash  and  premature  operation  is  fatal  ?  It  is  an  axiom  which  should 
be  deeply  engraved  on  the  memory  of  the  accoucheur,  and  which 
should  constantly  influence  his  conduct.  Pain  and  suffering  are 
the  immediate  consequence  of  the  practice ;  whilst  a  repetition  of 
the  flooding  after  delivery,  or  the  accession  of  inflammation,  are 
the  messengers  of  death. 

It  was  the  fatal  consequence  of  this  blind  practice  that  suggested 
to  M.  Puzos  the  propriety  of  puncturing  the  membranes,  and  thus 
endeavouring  to  excite  labour.  His  reasoning  was  ingenious  ;  his 
proposal  was  a  material  improvement  on  the  practice  which  then 
prevailed.  The  ease  of  the  operation,  and  its  occasional  success, 
recommend  it  to  our  notice ;  but  experience  has  now  determined 
that  it  cannot  be  relied  on,  and  that  it  may  be  dispensed  with.  If 
we  use  it  early,  and  on  the  first  attack,  we  do  not  know  when  the 
contraction  may  be  established ;  for,  even  in  a  healthy  uterus, 
when  we  use  it  on  account  of  a  deformed  pelvis,  it  is  sometimes 
several  days  before  labour  be  produced.  We  cannot  say  what  may 
take  place  in  the  interval.  The  uterus  being  slacker,  the  hemor- 
rhage is  more  apt  to  return,  and  we  may  be  obliged,  after  all,  to 
have  recourse  to  other  means,  particularly  to  the  plug.  Now,  we 
know  that  the  plug  will,  without  any  other  operation,  safely  re- 
strain hemorrhage,  until  the  os  uteri  be  in  a  proper  state  for  deli- 
very.f  The  proposal  of  M.  Puzos  then  is,  I  apprehend,  inadmis- 
sible before  this  time.  If,  after  this,  there  be  occasion  to  interfere, 
it  is  evident  that  we  must  desire  some  interference  which  can  be 
depended  on,  both  with  respect  to  time  and  degree.  This  method 
can  be  relied  on  in  neither ;  for  we  know  not  how  long  it  may  be 

*  Vide  the  Works  of  Mauriceau,  Peu,  &c. 

f  The  ingenious  M.  Alphonse  Le  Roy  seems  much  inclined  to  trust  almost 
entirely  to  the  plug,  and  supposes  that  the  blood  will  act  as  a  foreign  body,  and 
excite  contraction ;  but  this,  as  a  general  doctrine,  must  be  greatly  qualified. 
Respecting  the  proposal  of  M.  Puzos,  he  observes,  "Puzos,  en  conseillant  assez 
hardiment  de  Percer  les  eaux,  n'avoit  d'autres  vues  que  la  contraction  de  lama- 
trice,  qui  est  la  suite  de  cette  operation  et  la  cessation  de  la  perte,  et  il  la  con- 
seilla  meme  dans  les  cas  des  pertes  qu'arrivent  avant  terme.  Mais  un  grand  nom- 
bre  de  femmes  sont  peries  par  l'effect  de  cette  meme  pratique."  Lepons  sin- 
ks pertes  dc  sang,  p.  45. 

43 


330' 

erf  exciting  contraction,  nor  whether  it  may  be  able  to  excite  effec- 
tive contraction  after  any  lapse  of  time.  If  it  fail,  we  render  deli- 
very more  painful,  and  consequently  more  dangerous  to  the  mo- 
ther, and  bring  the  child  into  hazard.  It  has  been  observed,  in 
objection  Jo  this,  by  Dr.  Denman*  that  if  turning  be  difficult,  the 
flooding  will  be  stopped  by  the  contraction  of  the  womb.  But  we 
know  that  the  uterus,  emptied  of  its  water,  may  embrace  the  child 
so  closely  as  to  render  turning,  if  not  difficult,  at  least  painful,  and 
yet  not  be  acting  so  briskly  as  to  restrain  flooding :  nothing  but 
brisk  contraction  can  save  a  patient  in  flooding,  if  the  vessels  be 
large  or  numerous.     Spasmodic  action  may  also  take  place. 

The  only  case  then  which  remains  to  be  considered,  is  that  in 
which  pains  come  on,  and  expulsion  is  going  forward.  Now, 
in  this  case,  the  flooding  is  stopped  either  by  the  contraction 
or  by  the  plug,  and  the  membranes  burst  in  the  natural  course 
of  labour ;  after  which  it  is  speedily  concluded.  Here,  then,  in- 
terference is  not  required  ;  but  if,  after  going  on  in  a  brisk  way  for 
some  time,  the  pains  abate  a  little,  which  often  happens  even  in  a 
natural  labour,  it  will  be  proper  to  rupture  the  membranes,  if  we 
have  reason  to  think  that  a  slight  stimulus  to  the  uterus  would  renew 
its  action  :  and  in  determining  this,  the  practitioner  must  be  influ- 
enced by  the  previous  discharge;  for  if  the  uterus  have  been  much 
reduced  by  it  in  its  vigour,  it  will  be  less  under  the  influence  of  a 
stimulus ;  and  if,  upon  the  present  diminution  of  the  pains,  the 
flooding  is  disposed  to  return,  I  should  think  that  we  surely  ought 
to  trust  rather  to  the  hand,  which  can  stimulate  in  the  necessary 
degree,  and  finish  the  process  with  safety,  than  to  a  method  which 
is  much  more  uncertain  and  less  under  our  command.f 

The  proposal  of  M.  Puzos  then  will,  if  this  reasoning  be  just,  be 

*  Introduction  to  the  Practice  of  Midwifery,  Vol.  II.  p.  310. 

j-  In  those  cases  where  the  placenta  presents,  few  practitioners  would  think  of 
trusting  to  the  evacuation  of  the  liquor  amnii ;  they  would  deliver.  If  then  de- 
livery be  considered  as  safe  and  proper  in  one  species  of  flooding,  it  cannot  be 
dangerous  in  the  other ;  and  whenever  interference  in  the  way  of  operation  is 
necessary,  the  security  afforded  by  the  introduction  of  the  hand  will  much  more 
than  compensate  for  any  additional  pain.  But  even  in  this  respect,  the  two  ope 
rations  are  little  different,  if  properly  performed. 


331 

very  limited  in  its  utility.  Its  simplicity  gave  me  at  first  a  strong 
partiality  in  its  favour  ;  but  I  soon  found  cause  to  alter  my  opinion. 

There  still  remains  a  most  important  question  to  be  answered. 
In  those  cases  where  the  patient  has  been  allowed  to  lose  a  great 
deal  of  blood  frequently  and  suddenly,  when  the  strength  is  gone, 
the  pulse  scarcely  to  be  felt,  the  extremities  cold,  the  lips  and 
tongue  without  blood,  and  the  eye  ghastly,  shall  we  venture  to  de- 
liver the  woman  ?  Shall  we,  by  plugging,  endeavour  to  prevent 
farther  loss,  and  by  nourishment  and  care  recruit  the  strength  ;  or 
empty  the  uterus,  and  then  endeavour  to  restore  the  loss  ?  We 
have  only  a  choice  of  two  dangers.  The  situation  of  the  patient 
is  most  perilous,  and  I  have  in  practice  weighed  the  argument  with 
that  attention  which  the  awful  circumstances  of  the  case  required. 
1  think  myself  justified  in  saying,  that  we  give  both  mother  and 
child  the  best  chance  of  surviving  by  a  cautious  delivery.  For  in 
these  cases  the  uterus  is  almost  torpid,  it  possesses  no  tonic  con- 
traction;* the  very  continuance  of  the  ovum  within  it  is  more  than 
it  can  bear.  The  general  system  is  completely  exhausted,  and 
cannot  support  its  condition  long.  I  have  never  known  a  woman 
live  twenty-four  hours  in  these  circumstances. 

On  the  other  hand,  I  grant,  that  it  is  possible  the  woman  may  die 
in  the  act  of  delivery,  or  very  soon  after  it;  but  if  she  can  be  sup- 
ported for  two  days,  we  may  have  hopes  of  recovery.  By  a  very 
slow  and  cautious  delivery,  and  by  endeavouring  thereafter,  by  re- 
taining the  hand  for  some  time  in  the  womb,  to  excite  its  action, 
so  as  to  prevent  discharge  afterwards,  we  not  only  remove  the  irri- 
tation of  the  distended  womb,  but  we  likewise  take  away  a  recep- 
tacle of  blood.  During  the  contraction  of  the  uterus,  the  blood  in 
its  sinuses  will  be  thrown  into  the  system,  and  tend  to  support  it. 
Part,  no  doubt,  will  escape ;  but  by  keeping  the  hand  in  the  uterus, 
by  supporting  the  abdomen  with  a  compress,  and  exciting  the  ute- 
rine action  by  cold  applications  to  the  belly,  we  may  prevent  a 
great  loss.     When  to  these  considerations  we  add  the  additional 

*  The  use  of  the  plug  cannot  here  certainly  prevent  the  farther  loss  of  blood, 
for  the  uterus  affords  no  resistence,  the  hemorrhage  continues,  and  after  death 
large  coagula  will  be  found  within  the  womb. 


332 

chance  which  the  child  has  for  life,  our  practice,  I  apprehend,  will, 
in  this  very  hazardous  case,  be  decided.  When  the  pulse  becomes 
firmer  and  fuller  upon  the  contraction  of  the  uterus,  the  risk  from 
debility  is  diminished.  A  full  dose  of  laudanum  ought  uniformly 
to  be  given  previous  to  delivery,  as  I  have  formerly  advised ;  and 
afterwards,  forty  drops  of  the  same  medicine  are  to  be  given  at 
stated  intervals,  in  order  to  support  the  strength.  In  the  course  of 
two  days,  several  hundred  drops  may  be  given,  without  affecting 
the  head,  or  producing  stupor.  If  the  stomach  be  irritable,  solid 
opium  may  be  given,  or  an  opiate-clyster  is  to  be  administered. 
This  practice  does  not  rest  on  my  own  experience  alone,  but  is 
corroborated  also  by  that  of  Dr.  Hamilton,  the  justly  celebrated 
Professor  of  Midwifery  in  Edinburgh.  Small  quantities  of  light 
nourishment  must  also  be  given  frequently,  and  a  state  of  rest 
strictly  enforced,  in  so  much,  that  the  patient,  for  some  time  after 
delivery,  ought  not  even  to  be  shifted,  but  only  a  firm  bandage 
applied  over  the  abdomen,  in  order  to  support  the  muscles  and 
contained  viscera ;  and  this  is  a  precaution  which  never  ought  to 
be  omitted. 

At  one  time  it  was  supposed  that  the  placenta  was,  in  every  in- 
stance, attached  originally  to  the  fundus  uteri,  and  that  it  could 
only  be  found  presenting  in  consequence  of  having  been  loosened 
and  falling  down.  This  accident  was  supposed  to  retard  the  birth 
of  the  child,  by  stopping  up  the  passage,  and  also  was  considered 
as  dangerous  on  account  of  the  flooding  which  attended  it.  On 
this  account  Daventer  endeavoured  to  accelerate  the  delivery  by 
tearing  the  placenta,  or  rupturing  the  membranes  when  they  could 
be  found.  This  was  a  dangerous  practice,  and  very  few  survived 
when  it  was  employed.  Mr.  GifFord  and  M.  Levret*  were  among 
the  first  who  established  it  as  a  rule  that  the  placenta  did  not  fall 

*  Je  m'engage  a  prouver  lmo.  que  le  placenta  s'implante  quelquefois  sur  la 
circonferen.ee  de  l'orifice  de  la  matrice;  e'est-a-dire,  sur  celui  qui  ducol  vajoin- 
dre  l'interieur  de  ce  viscere,  et  non  sur  celui  qui  regarde  de  la  vagin. 

2do.  Qu'en  ce  cas  la  perte  de  sang  est  inevitable  dans  les  dernier  terns  de  la 
grossesse. 

Et  otio.  Qu'il  n'y  a  pas  de  vo)  e  plus  sure  pour  remedier  a  cet  accident  urgent 
que  de  fair  l'accouchement  force. — L'art  des  Accouchemens,  p.  343. 


333 

down,  but  was,  from  the  first,  implanted  over  the  os  uteri :  and 
the  latter  gentleman  published  a  very  concise  and  accurate  view 
of  the  treatment  to  be  pursued. 

We  know,  that,  during  the  eighth  month  of  gestation,  very  con- 
siderable changes  take  place  about  the  cervix  uteri.  It  is  com- 
pletely developed  and  expanded ;  and  in  the  ninth  month,  very 
little  distance  intervenes  betwixt  the  ovum  and  the  lips  of  the  os 
uteri.  These  changes  cannot  easily  take  place  without  a  rupture 
of  some  of  the  connecting  vessels ;  for  either  the  placenta  does  not 
adapt  itself  to  the  changes  in  the  shape  of  the  cervix,  or,  which 
happens  more  frequently,  some  slight  mechanical  cause,  or  action 
of  the  fibres  about  the  os  uteri,  produces  a  rupture. 

This  rupture  may  doubtless  take  place  at  any  period  of  preg- 
nancy,* but  it  is  much  more  frequent  in  the  end  of  the  eighth  and 
beginning  of  the  ninth  month,  than  at  any  other  time.  But  whe- 
ther the  separation  happens  in  the  seventh,  eighth,  or  ninth  month, 
the  consequent  hemorrhage  is  always  profuse,,  and  the  effects  most 
alarming.  The  quantity,  but  especially  the  rapidity,  of  the  dis- 
charge, very  frequently  produce  a  tendency  to  faint,  or  even  com- 
plete syncope,  during  which  the  hemorrhage  ceases,  and  the  wo- 
man may  continue  for  several  days  without  experiencing  a  renew- 
al of  it.  In  some  instances  she  is  able  to  sustain  many  and 
repeated  attacks,  which  may  take  place  daily  for  some  weeks. 
These,  however,  it  is  evident,  cannot  be  very  severe,  and  the 
strength  must  originally  have  been  great.  In  other  instances,  the 
woman  never  gets  the  better  of  the  first  attack.  It,  indeed,  dimi- 
nishes, but  does  not  altogether  leave  her,  and  a  slight  exertion  re- 
news it  in  its  former  violence.  But  whether  the  patient  suffer 
much  or  little  in  the  first  attack — whether  she  be  feeble  or  robust, 
the  practice  must  be  prompt,  and  the  most  solemn  call  is  made 
upon  the  practitioner  for  activity.  The  moment  that  a  discharge 
of  blood  takes  place,  he  ought  to  ascertain,  by  careful  examina- 
tion, the  precise  nature  of  the  case,  and  must  take  instant  steps 

*  In  some  cases,  hemorrhage  has  taken  place  so  early  as  the  third  month.  By 
proper  means  this  has  been  stopped,  and  the  patient  has  continued  well  for  some 
months,  when  the  flooding  has  returned,  and  the  placenta  been  discovered  to 
present. 


334 

for  checking  it,  if  nature  have  not  already  accomplished  that 
event. 

If  the  os  uteri  be  firm  and  close  in  a  first  attack,  we  ought  to  use 
the  plug,  which  will  restrain  the  hemorrhage,  and  insure  the  pre- 
sent safety  of  the  patient.  If  this  practice  have  been  immediately 
followed,  she  shall  in  general  soon  recover,  and  the  length  of  time 
for  which  she  shall  remain  free  from  a  second  attack  will  depend 
very  much  upon  the  care  which  is  taken  of  her  ;  but  sooner  or 
later  the  attack  must  and  will  return.  If  the  uterus  have  been  in- 
jured in  its  action  by  the  first  attack,  this  will  generally  be  attended 
with  very  slight  dull  pains,  and  we  shall  feel  the  os  uteri  more  open 
and  laxer  than  usual ;  but  if  the  first  and  second  discharges  have 
been  promptly  checked,  it  may  be  later  before  these  effects  be  per- 
ceived ;  but  the  moment  that  they  are  produced,  we  ought  to  de- 
liver ;  and  it  should  even  be  a  rule,  that  where  they  are  not  likely 
soon  to  take  place,  and  the  discharge  has  been  profuse  and  rapid, 
and  produced  those  effects  on  the  system  which  I  have  already 
pointed  out,  as  the  consequence  of  dangerous  hemorrhage,  we  must 
not  delay  until  pains  begin  to  open  the  os  uteri.  Fortunately,  we 
are  not  often  obliged  to  interfere  thus  early ;  for  by  careful  manage- 
ment, and  the  use  of  the  plug,  we  can  secure  our  patient. 

Although  I  have  said  that  we  may  wait  safely  until  the  os  uteri 
begins  to  open,  and  asserted,  that  no  woman  can  die  from  mere 
hemorrhage,  before  the  state  of  the  os  uteri  admit  of  delivery,  I 
must  yet  add,  on  this  important  subject,  that  this  state  does  not  con- 
sist merely  in  dilatation,  for  it  may  be  very  little  dilated,  but  in 
dilatability ;(g)  we  may  safely  deliver  whenever  the  hand  can  be 
introduced  without  much  force.  A  forcible  introduction  of  the  hand 

CgJ  Rigby,  a  respectable  surgeon  of  Norwich,  in  England,  is  entitled,  as  we 
believe,  to  the  credit  of  first  promulgating  this  distinction,  which  is  of  great  im- 
portance to  be  attended  to  in  practice  ;  his  words  are,  "  We  should  be  as  much 
influenced  (as  respects  the  period  of  introducing  the  hand)  by  the  os  uteri  being 
in  a  state  capable  of  dilatation  without  violence,  as  by  its  being  really  open  ;  when 
this  is  the  case,  therefore,  if  the  woman's  situation  demand  speedy  assistance, 
we  should  not  hesitate  to  attempt  delivery."  His  Essay  on  this  subject,  was 
published  in  the  year  1777,  and  is  in  every  respect  a  valuable  work,  rendered 
more  so  by  the  number  of  interesting  cases  appended  to  it.  It  has  been  repub- 
lished in  this  city,  and  is  highly  worthy  of  the  perusal  of  every  student  and  prac- 


335 

on  the  first  attack  of  hemorrhage,  would,  in  many  cases,  be  attend- 
ed with  the  greatest  danger,  and  in  almost  every  case  is  improper 
and  unnecessary.  I  have  never  yet  seen  an  instance,  where  delivery 
was  required  during  the  first  paroxysm,  if  the  proper  treatment  was 
followed.  Whether  it  may  be  required  in  a  second  or  third  attack, 
or  even  later,  must  depend  upon  the  quantity  and  rapidity  of  the 
discharge,  its  effects,  and  the  strength  of  the  woman.  But  when- 
ever we  find  the  os  uteri  softer,  and  in  any  degree  more  open  than 
in  its  usual  state  before  labour,  admitting  the  finger  to  be  intro- 
duced easily  within  it,  we  may  deliver  safely ;  and  if  the  hemor- 
rhage be  continuing,  ought  not  to  delay.  This  state  will  generally 
be  found  accompanied  with  obscure  pains ;  but  we  attend  less  to 
the  degree  of  pain  than  of  discharge,  in  determining  on  delivery. 
The  pains  gradually  increase  for  a  certain  period,  and  then  go  off. 
During  their  continuance,  the  os  uteri  dilates  more ;  but  if  the  he- 
morrhage have  been,  or  continues  to  be  considerable,  we  must  not 
wait  until  the  os  uteri  be  much  dilated,  as  we  thus  reduce  the  wo- 
man to  great  danger,  and  diminish  the  chance  of  her  recovery.  A 
prudent  practitioner  will  not,  on  the  one  hand,  violently  open  up 
the  os  uteri  at  an  early  period,  but  will  use  the  plug,*  until  the  os 
uteri  become  soft  and  dilatable  ;  and  if  the  hemorrhage  be  not  con- 
siderable, he  will  even,  if  the  state  of  the  patient  allow  him,  wait 
until  slight  pains  have  appeared,  or  the  os  uteri  begin  sensibly  to 
open  without  them ;  for  he  will  recollect  that  the  more  violence 
that  is  done  to  the  os  uteri,  the  greater  is  the  risk  of  bad  symptoms 
supervening.  It  is  an  error  into  which  some  have  fallen,  who  look 
upon  debility  from  discharge  as  the  only  barrier  to  recovery.  Vio- 
lent delivery  may  produce  inflammation,  or  a  very  troublesome 
fever.  On  the  other  hand,  he  will  not  allow  his  patient  to  lose  much 
blood,  or  have  many  attacks ;  he  will  deliver  her  immediately,  for 

titioner  of  midwifery.  Its  title  is,  "An  Essay  on  the  Uterine  Hemorrhage,  which 
precedes  the  delivery  of  the  full  grown  Foetus  :  illustrated  with  cases  by  Edward 
Rigby,  member  of  the  Corporation  of  Surgeons  in  London." 

*  Gardien  thinks,  that  in  such  cases,  the  plug  will  do  harm  by  exciting  the  ute- 
rus to  detach  more  of  the  placenta,  and  thus  increase  the  hemorrhage,  T.  ii.  p. 
404. 


336 

he  knows  that  whenever  this  is  necessary,  it  is  easy,  the  os  uteri 
yielding  to  his  cautious  endeavours. 

But  very  frequently  we  are  not  called  until  the  patient  have  had 
one  or  two  attacks ;  and  been  reduced  to  great  danger.  We  find 
her  with  feeble  pulse,  ghastly  countenance,  frequent  vomiting,  and 
complaining  occasionally  of  slight  pains.  On  examination,  the  va- 
gina is  so  filled  with  clotted  blood,  adhering  firmly  by  the  lymph  to 
the  uterus,  that  at  first  we  find  some  difficulty  in  discovering  the  os 
uteri.  We  cannot  here  hesitate  a  moment  what  course  to  follyw. 
If  the  patient  is  to  be  saved,  it  is  by  delivery.  The  os  uteri  will  be 
in  part  dilated ;  it  may  easily  be  fully  opened.  We  perhaps  find 
an  edge  of  the  placenta  projecting  into  the  vagina,  perhaps  the 
centre  of  the  placenta  presenting  or  protruding  like  a  cup  into  the 
vagina ;  but  in  those  cases  the  rule  is  the  same.  We  pass  by  the 
placenta  to  the  membranes,  rupture  them,*  and  turn  the  child,  de- 
livering according  to  the  directions  which  I  have  already  given,  and 
treating  the  patient  in  all  other  respects  in  the  exhibition  of  opiates 
and  cordials  and  nourishment,  and  exciting  the  subsequent  contrac- 
tion of  the  womb,  as  in  the  case  formerly  considered. 

It  may  be  supposed,  that  as  the  treatment  is  so  nearly  the  same, 
it  is  not  material  that  we  distinguish  whether  the  placenta  or  mem- 
branes present.  But  it  is  convenient  to  make  a  distinction,  be- 
cause in  those  cases  where  the  placenta  does  not  present,  it  is  pos- 
sible, in  certain  circumstances,  to  cure  the  flooding,  and  carry  the 
patient  to  the  full  time  ;  and  in  those  cases,  which  are  indeed  the 
most  numerous,  where  this  cannot  be  done,  we  always  look  to  ute- 
rine contraction  as  a  very  great  assistance,  and  expect  that  where 
that  is  greatest,  the  danger  will  be  least.  But  when  the  placenta 
presents,  we  have  no  hope  of  conducting  the  woman  safely  to  the 
full  time.  We  have  no  ground  to  look  to  contraction  or  labour 
pains  as  a  mean  of  safety ;  for,  on  the  contrary,  every  effort  to  di- 
late the  os  uteri  separates  still  more  the  placenta,  and  increases  the 
hemorrhage.f     The  very  circumstance  which  in  some  other  cases 

*  This  is  much  safer  for  the  child  than  pushing  the  hand  through  the  placenta ; 
and  it  is  equally  advantageous  for  the  mother,  and  easy  to  the  operator. 

j-The  greatest  number  of  profuse  or  alarming  hemorrhages  proceed  from  the 
presentation  of  the  placenta,  or  the  implantation  of  its  margin  over  the  os  uteri ; 


337 

would  save  the  patient,  will  here,  in  general,  increase  the  danger. 
I  say  in  general,  lor  there  are  doubtless  examples  where  the  pati- 
ent has  by  labour  been  safely,  and  without  assistance,  delivered  of 
the  child,  when  part  of  the  placenta  has  presented.  Nay,  there 
have  been  instances  where  the  placenta  has  been  expelled  first, 
and  the  child  after  it.*  These  examples  are  to  be  met  with  in  col- 
lections of  cases  by  practical  writers  ;  and  some  solitary  instances 
are  likewise  to  be  found  in  different  journals.  It  would  be  much 
to  be  lamented  if  these  should  ever  appear  without  having,  at  the 
same  time,  a  most  solemn  warning  sent  along  with  them  to  the  ac- 
coucheur, to  pay  no  attention  to  them  in  his  practice.f  I  am  con- 
vinced that  they  may  do  inexpressible  mischief,  by  affording  argu- 
ment for  delay,  and  excusing  the  practitioner  to  himself  for  pro- 
crastination. There  is  scarcely  any  malady  so  very  dreadful  as 
not  to  afford  some  examples  of  a  cure  effected  by  the  powers  of 
nature  alone ;  but  ought  we  thence  to  tamper  with  the  safety  of 
those  whose  lives  are  committed  to  our  charge  ?  Oua;ht  we  to  ne- 
glect the  early  and  vigorous  use  of  an  approved  remedy,  because 
the  patient  has  not  in  every  instance  perished  from  the  negligence 
of  the  attendant  ?  It  is  highly  proper  to  publish  the  case  of  a  pati- 
ent who,  from  hernia,  has  had  an  anus  formed  at  his  groin,  because 
it  adds  to  our  stock  of  knowledge  :  But  what  should  we  think  of  a 
surgeon  who  should  put  such  a  case  into  the  hands  of  a  young  man 
without,  at  the  same  time,  saying,  "  Sir,  if  such  a  case  ever  hap- 
pen in  your  practice,  either  you  or  your  patient  will  be  very  much 
to  blame."  I  do  not  mean  from  this  to  say  that  we  are  to  blame, 
in  every  instance,  the  accoucheur  who  has  attended  a  case  where 
the  placenta  has  presented,  and  the  patient  been  delivered  by  na- 
ture :  far  from  it,  for  by  the  use  of  the  plug,  he  may  have  restrain- 
ed the  hemorrhage,  pains  may  have  come  on,  and  the  child,  de- 

and  consequently,  the  greatest  number  of  cases  requiring-  delivery  are  of  this 
kind. 

*  Even  in  those  cases  where  the  placenta  is  expelled  first,  the  flooding  ni3y  re- 
cur, and  the  woman  die,  if  she  be  not  assisted.  Vide  La  Motte.  Obs.  ccxxxviii. 
and  ccxxxix. 

■(■  Most  of  those  who  have  met  with  such  cases,  do  not  seem  to  count  much 
upon  them. 

44 


338 

sccnding  may  have  carried  the  plug  before  it :  or  when  he  was  call- 
ed to  his  patient,  he  may  have  found  her  alrealy  in  labour,  and  the 
process  going  on  so  well  and  so  safely,  that  all  interference  would 
have  been  injudicious.  But  these  instances  are  not  to  be  convert- 
ed into  general  rules,  nor  allowed  to  furnish  any  pretext  for  pro- 
crastination. They  happen  very  seldom,  and  never  ought  to  be 
related  to  a  young  man  without  an  express  intimation  that  he  is 
not  to  neglect  delivery,  when  it  is  required,  upon  any  pretence 
whatsoever. 

§  38.  FALSE  PAINS. 

Many  women  are  subject,  in  the  end  of  gestation,  to  pains  about 
the  back  or  bowels,  somewhat  resembling  those  of  labour,  but 
which,  in  reality,  are  not  connected  with  it.  These,  therefore, 
are  called  false  pains.  They  sometimes  only  precede  labour  a  kw 
hours  ;  but  in  many  cases,  they  come  on  several  days,  or  even 
some  weeks,  before  the  end  of  pregnancy,  and  may  be  very  fre- 
quently repeated,  especially  during  the  night,  depriving  the  woman 
of  sleep.  They  are  often  confined  altogether  to  the  belly,  shifting 
their  place,  and  being  very  irregular  both  in  their  attacks  and  con- 
tinuance. In  some  cases  they  affect  the  side,  particularly  the  right 
side,  in  the  region  of  the  liver,  and  are  exceedingly  severe,  espe- 
cially in  the  evening  ;  they  are  accompanied  with  acidity  or  wa- 
ter-brash, or  retching,  and  generally  the  child  is  at  that  time  very- 
restless.  These  pains  may  doubtless  occur  in  any  habit,  but  they 
most  frequently  harass  those  who  are  addicted  to  the  use  of  cor- 
dials. On  other  occasions,  the  false  pains  occupy  chiefly  the  back 
or  hips,  or  upper  part  of  the  thighs.  They  even  sometimes  re- 
semble still  more  nearly  parturient  pains,  in  being  attended  with 
an  involuntary  effort  on  the  part  of  the  abdominal  muscles,  to  press 
down,  so  as  to  make  the  woman  suppose  that  she  is  about  to  be 
delivered  ;  and  this  is  occasionally  accompanied  with  tenesmus, 
or  with  protrusion  of  the  bladder  from  the  vagina,  very  like  the 
membranes  of  the  ovum.  In  other  cases,  they  are  attended  with 
a  discharge  of  watery  fluid  from  the  vagina.  False  pains  may  be 
occasioned  by  many  causes :  the  most  frequent  are  flatulence  ;  a 


339 

spasmodic  state  of  the  bowels,  resembling  slight  colic  ;  or  irrita- 
tion, connected  with  costiveness  or  diarrhosa  ;  or  nephritic  affec- 
tions, often  accompanied  with  strangury.  A  sudden  motion  of  the 
back,  or  unusual  degree  of  fatigue,  may  cause  a  remitting  pain  in 
the  back  and  loins  ;  or  getting  suddenly  out  of  bed  when  warm, 
and  placing  the  feet  on  the  cold  floor,  may  have  the  same  effect. 
A  slight  degree  of  lumbago  may  also  resemble  the  parturient  pains. 
Agitation  of  mind,  or  a  febrile  state  of  the  body,  or  some  irri- 
tation in  the  neighbourhood  of  the  uterus,  or  some  unusual  motion 
of  the  child,  may  produce  an  uneasy  sensation  in  the  uterus  ;  and 
sometimes  this  is  accompanied  by  a  discharge  of  watery  fluid  from 
the  vagina.  Other  uterine  irritations  may  excite  painful  action  in 
the  uterus  itself,  or  sympathetically  in  other  parts,  as  the  intestines 
or  muscles  of  the  abdomen.  Amongst  these  irritations  may  be 
mentioned  that  which  sometimes  attends  the  full  development  of 
the  cervix  in  the  last  weeks  of  gestation,  or  the  expansion  of  the 
portion  immediately  adjoining  the  os  uteri. 

False  pains  may  often  be  distinguished  by  their  situation  ;  as 
for  instance,  when  they  affect  the  bowels  or  kidneys ;  by  their 
shifting  their  situation ;  by  their  duration  ;  by  their  irregularities  ; 
and  by  the  symptoms  with  which  they  are  attended.  But  the  best 
criterion  is,  that  they  are  not  attended  with  any  alteration  in  the 
uterine  fibres,  which,  during  true  or  efficient  labour  pains,  contract 
so  as  to  render  the  uterus  more  compact,  and  make  it  feel  harder 
when  the  hand  is  placed  over  it  on  the  abdomen.  They  also  sel- 
dom affect  the  os  uteri,  that  part  not  being  dilated  during  their  con- 
tinuance. It  is  necessary  however,  to  observe,  that  a  dilated  state 
of  the  os  uteri  does  not  always  prove  that  the  pains  are  those  of  la- 
bour ;  for  it  may  be  found  prematurely  dilated,  to  a  slight  degree, 
before  the  proper  term  of  labour,  without  any  pain.  In  this  case, 
if  the  pains  proceed  from  affections  of  the  bowels,  no  effect  is  pro- 
duced during  the  pain,  in  rendering  the  os  uteri  tense,  or  making 
it  larger.  On  the  other  hand,  it  sometimes  happens,  that  the  fibres 
about  the  os  uteri  are  prematurely  irritated  ;  and  this  stale  may  be 
accompanied  with  pain,  and  with  a  perceptible  change  on  the  os 
uturi  during  a  pain.  This  is  a  very  ambiguous  case  ;  but  we  may 
"he  assisted  in  our  judgment,  by  discovering,  that  the  term  of  utero- 


340 

gestation  is  not  completed,  that  the  os  uteri  is  hard  or  thick,  and 
the  pains  irregular,  both  in  severity  and  duration,  coming  on  at 
long  intervals,  or  being  frequently  repeated  for  some  hours,  and 
then  going  altogether  off  for  so  many  more,  and  thus  perhaps  con- 
tinuing even  for  several  days.  This  seems  sometimes  to  depend 
on  preternatural  sympathy  of  the  neighbouring  parts  with  the  os 
uteri,  so  that  when  it  begins  to  dilate,  the  abdominal  or  perineal 
muscles,  he.  are  excited  to  painful  action,  which,  on  the  principle 
of  the  sympathy  of  equilibrium,  which  I  have  elsewhere  explain- 
ed, immediately  calls  off  the  uterine  action,  which  for  a  long  time 
rather  excites  those  other  parts  to  unprofitable  pain,  than  establish- 
es itself  into  regular  labour.  In  all  such  cases,  it  is  best  to  proceed 
on  the  supposition,  that  the  woman  is  not  actually  in  labour.  By 
letting  her  alone,  she  most  likely  will  have  a  continuance  of  pain, 
terminating,  it  is  true,  in  labour,  but  the  process  will  be  tedious 
and  fatiguing ;  whereas,  by  suspending  the  action  by  an  opiate, 
and  if  necessary  by  venesection,  she  may  go  on  for  some  time  lon- 
ger, and  shall  at  all  events  have  an  easier  delivery. 

When  the  false  pains  are  accompanied  with  a  febrile  state,  or 
are  very  distressing  during  the  night,  it  will  be  proper  to  detract 
blood,  and  afterwards  give  an  anodyne.  In  all  other  cases,  it  is 
generally  sufficient  to  keep  the  woman  in  a  state  of  rest;  open  the 
bowels  by  means  of  a  clyster,  if  there  be  no  diarrhoea,  and  after- 
wards give  an  opiate  to  be  succeeded  by  a  laxative.  Rubbing 
with  anodyne  balsam  is  also  useful,  or  gentle  friction  with  the  flesh 
brush.  Motion  also  often  relieves  the  muscular  pain,  whilst  a 
quiescent  state  increases  it,  and  hence  it  is  in  many  cases  worst 
during  the  night.  In  other  instances,  the  erect  posture  or  walking, 
probably  from  irritation  of  the  cervix  and  os  uteri,  by  pressure  of 
the  child's  head,  excites  pain. 

Shivering  and  tremor  occur  in  some  cases,  in  the  end  of  preg- 
nancy; and  as  they  also  occasionally  precede  labour,  they  often 
give  rise  to  an  unfounded  expectation,  that  delivery  is  approach- 
ing. They  appear  to  be  connected  sometimes  with  the  state  of 
the  stomach,  or  alimentary  canal;  in  other  instances  with  some 
change  in  the  os  uteri  itself,  which  even  without  pain,  may  be  so 
far  opened  or  relaxed  as  to  allow  the  finger  very  easily  to  toucli 


341 

the  child's  head  through  the  membranes.  It  is  usually  in  the 
evening,  or  through  the  night,  that  the  shivering  is  felt ;  and  it  is 
occasionally  pretty  severe,  and  may  be  several  times  repeated. 
Nothing,  however,  is  required,  except  a  little  warm  gruel,  or  v 
moderate  dose  of  laudanum,  which  is  always  effectual. 


THE 

PRINCIPLES 

OF 


BOOK  II. 

OF  PARTURITION. 

CHAP.  I. 

Of  the  Classification  of  Labours. 

LABOUR  may  be  defined  to  be  the  expulsive  effort  made  by 
the  uterus  for  the  birth  of  the  child,  after  it  has  acquired  such  a  de- 
gree of  maturity,  as  to  give  it  a  chance  of  living  independently  of 
its  uterine  appendages. 

I  propose  to  divide  labours  into  seven  classes;  but  I.do  not  con- 
sider the  classification  to  be  of  great  importance,  nor  one  mode  of 
arrangement  much  better  than  another,  for  the  purposes  of  practice, 
provided  proper  definitions  be  given,  and  plain  rules  delivered,  ap- 
plicable to  the  different  cases. 

The  classes  which  I  propose  to  explain  are, 
Class  I.  Natural  Labour;  which  I  define  to  be  labour  taking  place 
at  the  end  of  the  ninth  month  of  pregnancy;  the  child  pre- 
senting the  central  portion  of  the  sagittal  suture,  and  the  fore- 
head being  directed  at  first  toward  the  sacro-iliac  symphysis ; 
a  due  proportion  existing  betwixt  the  size  of  the  head,  and  the 
capacity  of  the  pelvis :  the  pains  being  regular  and  effective ; 


344 

the  process  not  continuing  beyond  twenty-four  hours,  seldom 
above  twelve,  and  very  often  not  for  six.  No  morbid  affection 
supervening,  capable  of  preventing  delivery,  or  endangering 
the  life  of  the  woman. 

This  comprehends  only  one  ovder.(a) 

faj  Our  author  might,  perhaps  with  propriety,  have  divided  this  class  into 
two  orders,  viz. 
Order  1.  The  posterior  fontanelle  of  the  child  presenting  towards  the  left  ace- 
tabulum, and  the  anterior  fontanelle,  or  forehead,  towards  the  right  sacro- 
iliac symphysis.    This  is  by  far  the  most  common  presentation. 
Order  2.  The  posterior  fontanelle  presenting  towards  the  right  acetabulum, 
and  the  anterior  fontanelle,  or  forehead,  towards  the  left  sacro-iliac  sym- 
physis. This  position  or  presentation,  according  to  Baudelocque,  occurs  but 
in  the  proportion  of  1  to  7  or  8  of  the  first. 
In  an  accurate  register  kept  by  Baudelocque,  it  appears,  that  of  12,183  presen- 
tations of  the  head,  10,003  were  of  the  first  position,  or  with  the  posterior  fonta- 
nelle towards  the  left  acetabulum,  and  2,113  in  the  second  position,  or  with  the 
posterior  fontanelle  towards  the  right  acetabulum. 

Classification  and  systematic  arrangement  generally,  are  most  frequently  purely 
artificial  and  arbitrary ;  and  that  of  our  author,  as  laid  down  above,  is  not  such  as 
we  can  cordially  approve,  but  as  his  division  of  the  subject  in  the  following  sec- 
tions is  founded  upon  it,  we  have  not  deemed  it  proper  to  propose  any  essential 
alteration.  The  great  and  deserved  celebrity  of  Baudelocque  as  a  practical  writer, 
seems,  notwithstanding,  to  demand  that  we  should  here  briefly  state  his  division 
of  the  presentations  of  the  vertex,  which  he  considers  as  natural. 

There  are  then,  according  to  bim,  six  positions  in  which  the  vertex  presents 
at  the  superior  strait,  viz. 

1.  The  posterior  fontanelle  is  situated  behind  the  left  acetabulum,  and  the  ante- 
rior before  the  right  sacro-iliac  symphysis. 

2.  The  posterior  fontanelle  is  situated  behind  the  right  acetabulum,  and  the  an- 
terior before  the  left  sacro-iliac  symphysis. 

3.  The  posterior  fontanelle  answers  to  the  symphysis  of  the  pubis,  the  anterior 
to  the  sacrum. 

4.  The  anterior  fonta7ielle  answers  to  the  left  acetabulum,  and  the  posterior  to 
the  right  sacro-iliac  symphysis. 

5.  The  anterior  fontanelle  is  situated  behind  the  right  acetabulum,  and  the  pos- 
terior before  the  left  sacro-iliac  symphysis. 

6.  The  anterior  fontanelle  is  behind  the  symphysis  of  the  pubis,  and  the  posterior 
before  the  sacrum. 

The  more  frequent  occurrence  of  the  1st.  and  2d.  than  of  the  4th.  and  5th.  is 
calculated  to  be  in  the.  proportion  of  80  or  100  to  1.  The  3d.  and  6th.  presenta- 
tions are  extremely  rare,  and  indeed  may  be  almost  considered  as  preternatural, 
or  pre-supposing  some  deformity  of  the  pelvis  or  fatal  head. 


344 

(jJlass  II.  Premature  Labour,  or  labour  taking  place  considerably 
before  the  completion  of  the  usual  period  of  utero-gestation, 
but  yet  not  so  early  as  necessarily  to  prevent  the  child  from 
surviving. 

This  comprehends  only  one  order. 
Class  III.  Preternatural  Labours,  or  those  in  which  the  presenta- 
tion, or  position  of  the  child  is  different  from  that  which  occurs 
in  natural  labour  ;  or  in  which  the  uterus  contains  a  plurality 
of  children,  or  monsters. 

This  comprehends  seven  orders. 
Order   1.   Presentation  of  the  breech. 
Order  2.  Presentation  of  the  inferior  extremities. 
Order  3.  Presentation  of  the  superior  extremities. 
Order  4.  Presentation  of  the  back,  belly,  or  sides  of  the  child. 
Order  5.  Malposition  of  the  head. 
Order  6.  Presentation  of  the  funis. 
Order  7.  Plurality  of  children,  or  monsters. 
■Glass  IV.   Tedious  Labour,  or  labour  protracted  beyond  the  usual 
duration ;   the  delay  not  caused   by  the  malposition  of  the 
child,  and  the  process  capable  of  being  finished  safely,  with- 
out the  use  of  extracting  instruments. 

This  comprehends  two  orders. 
Order  1.  Where  the  delay  proceeds  from  some  imperfection 

or  irregularity  of  muscular  action. 
Order  2.  Where  it  is  dependent  principally  on  some  mecha- 
nical impediment. 
£lass  V.  Laborious  or  Instrumental  Labour;  labour  which  cannot 
be  completed  without  the  use  of  extracting  instruments  ;  or 
altering  the  proportion  betwixt  the  size  of  the  child,  and  tlie 
.capacity  of  the  pelvis. 

This  comprehends  two  orders. 
Order  1.  This  case  admitting  the  use  of  such  instruments  as 
do  not  necessarily  destroy  the  child. 

It  will  be  observed,  that  in  the  arrangement  of  Our  author,  the  first  and  second 
positions  of  the  vextex  only  are  admitted  into  the  class  of  natural  labour,  whilst 
the  third,  fourth,  fifth  and  sixth  positions  of  Baudelocque,  are  thrown  into  tfa£ 
class  of  preternatural  labours  under  order  5.  Malposition  of  the  be»d , 

45 


34b 

Order  2.  The  obstacle  to  delivery  being  so  great,  as  to  re- 
quire that  the  life  of  the  child  should  be  sacrificed  for  the 
safety  of  the  mother. 
Class  VI.  Impracticable  Labour;  labour  in  which  the  child,  even 
when  reduced  in  size,  cannot  pass  through  the  pelvis. 
This  comprehends  only  one  order. 
Class  VII.   Complicated  Labour;  labour  attended  with  some  dan- 
gerous or  troublesome  accident  or  disease,  connected  in  par- 
ticular instances  with  the  process  of  parturition. 

This  comprehends  six  orders. 
Order  1.  'Labour  complicated  with  uterine  hemorrhage. 
Order  2.  Labour  complicated  with  hemorrhage  from  other 

organs. 
Order  3.  Labour  complicated  with  syncope. 
Order  4.  Labour  complicated  with  convulsions. 
Order  5.  Labour  complicated  with  rupture  of  the  uterus. 
Order  6.  Labour  complicated  with  suppression  of  urine,  or 
rupture  of  the  bladder. 
Calculations  have  been   made,  of  the  proportion  which  these 
different  kinds  of  labour  bear  to  each  other  in  practice.    Thus  Dr. 
Smellie  supposes,  that  out  of  a  thousand  women  in  labour,  eight 
shall  be  found  to  require  instruments,  or  to  have  the  child  turned,  in 
order  to  avoid  them ;  two  children  shall  present  the  superior  ex- 
tremities ;  five  the  breech ;  two  or  three  the  face  ;  one  or  two  the 
ear ;  and  ten  shall  present  with  the  forehead  turned  to  the  aceta- 
bulum. 

Dr.  Bland  has,  from  an  hospital  register,  stated  the  proportion 
of  the  different  kinds  of  labour,  to  be  as  follows:  of  1897  women, 
1792  had  natural  labour.  Sixty-three,  or  one  out  of  30,  had  un- 
natural labour;  in  18  of  these,  the  child  presented  the  feet;  in  36, 
the  breech;  in  8,  the  arm;  and  in  1,  the  funis.  Seventeen,  or 
one  out  of  111,  had  laborious  labour;  in  8  of  these,  the  head  of 
the  child  required  to  be  lessened;  in  4,  the  forceps  were  employed; 
and  in  the  other  5,  the  face  was  directed  towards  the  pubis.  Nine, 
or  one  in  210,  had  uterine  hemorrhage  before  or  during  labour. 
It  is  evident,  however,  that  this  register  cannot  form  a  ground  for 
general  calculation ;  and  the  reader  will  perceive,  that  the  number 


347 

of  crotchet  cases  exceeds  those  requiring  the  forceps,  which  is  nol 
observed  in  the  usual  course  of  practice.*  Dr.  Merriman  says, 
the  breech  presents  once  in  86,  the  feet  once  in  80,  and  the  arm 
once  in  170,  cases.  Dr.  Nagele,  in  the  hospital  of  Heidelberg, 
out  of  263  cases  there  were  four  twins;  256  children  presented 
the  head  ;  and  two  of  those  the  face;  5  the  breech  ;  3  the  feet;  1 
the  arm  ;  1  the  breast;  1  the  hip.  Hence,  1  in  26  cases  was  pre- 
ternatural.^ 

*  Farther  information  may  be  obtained,  by  consulting  the  Report  of  the  Dub- 
lin Lying-in  Hospital,  by  Dr.  Clarke  ;  and  that  of  the  Westminster  Hospital,  by 
Dr.  Granville. 

fbj  From  the  register  kept  at  l'Hospice  de  la  Maternite,  a  lying-in  hospital 
at  Paris,  under  the  direction  of  Baudelocque,  it  appears,  that  of  12,751  labours, 
12,573  at  least  were  natural :  the  assistance  of  art  being  necessary  in  178  cases 
only,  which  is  in  the  proportion  of  1  to  71|,  of  these, 

Cases- 
The  face  presented  in         -------        18 

The  shoulders      ---..-.-38 
The  head  and  umbilical  cord  -  -  -  -  -  -        15 

The  thighs  ---...,..  22 

The  feet        ------  11 

Other  parts  not  specified  ......  24 

Convulsions  and  floodings  ......         4 

As  1  to  96 1  132 

The  forceps  were  applied  in  37  cases,  which  is  as  1  to  3441. 

The  cranium  was  perforated,  or  the  crotchet  applied,  in  9  cases  only. 

Gastrotomy  was  performed  in  one  case  only,  and  that  to  extract  an  extra-ute- 
rine foetus. 

It  also  appears  from  a  late  periodical  publication,  that  there  were  admitted  into 
the  lying-in  hospital  at  Paris,  called  Maison  d'Accouchemens,  between  the  9th 
of  December,  1799,  and  the  31st  of  May,  1809, 17,308  women,  who  gave  birth  to 
17,499  children ;  of  which  number  16,286  were  presentations  of  the  vertex  to 
the  os  uteri. 


No. 

215  were  presentations  of  the  feet 

296  the  breech 

59  the  face 

52  one  of  the  shoulders 
4  the  side  of  the  thorax 


jrropu 
1  to 

riiuus. 

812 

1— 

59| 

1— 

296i 

1— 

33  6£ 

1— 

4374£ 

348 

We  Cannot  form  an  estimate  of  the  proportion  of  labours,  with 
much  accuracy,  from  the  practice  of  individuals,  as  one  man  may, 
from  particular  circumstances,  meet  with  a  greater  number  of  diffi- 
cult cases,  than  is  duly  proportioned  to  the  number  of  his  patients. 
Thus  Dr.  Hagen  of  Berlin  says,  that  out  of  350  patients,  he  em- 
ployed the  forceps  93  times,  and  the  crotchet  in  28  cases;  26  of 
his  patients  died.  Dr.  Dewees,  again,  of  Philadelphia,  says,  that 
in  more  than  3000  cases,  he  has  not  met  with  one  requiring  the 
use  of  the  crotchet. 


4  the  hip  - 

4  the  left  side  of  the  head    - 

4  the  knees  - 

4  the  head,  an  arm,  and  the  cord 

3  the  belly 

3  the  back     - 

3  the  loins 

1  the  occipital  region 

1  the  side,  with  the  right  hand 

1  the  right  hand  and  left  foot 

1  the  head,  and  the  feet     - 

2  the  head,  the  hand,  and  forearm 
37  the  head,  and  umbilical  cord 


4374$ 
4374| 
4374£ 
4374J 
5833 
5833 
5833 
17499 
17499 
17499 
17499 
8749* 
473 


Of  this  great  number  of  women,  230  were  delivered  by  art,  the  rest  were  natu- 
ral births,  being  in  the  proportion  of  1  to  76%  ;  161  were  delivered  by  the  hand 
alone,  the  children  being  brought  by  the  feet ;  49  were  delivered  by  the  forceps, 
either  on  account  of  the  small  dimensions  of  the  pelvis,  the  falling  down  of  the 
umbilical  cord,  or  the  wrong  position  of  the  head,  when  the  woman  was  exhaust- 
ed, or  her  life  was  in  danger  by  convulsions,  &c, ;  13  were  extracted  by  the 
crotchet  after  perforation  of  the  head,  on  account  of  mal-conformation  of  the 
pelvis  ;  in  these  instances  the  death  of  the  child  was  first  ascertained. 

The  cesarean  operation  was  performed  in  two  cases,  the  diameter  of  the  pel- 
vis being  only  one  inch  six  lines  from  sacrum  to  pubis. 

In  one,  the  section  of  the  symphysis  pubis  was  performed,  the  diameter  of  the 
pelvis  from  sacrum  to  pubis  being  only  two  inches  and  a  quarter. 

Gastrotomy  was  performed  once,  the  fcctus  being  extra-uterine ;  the  child 
weighed  81b.  2oz. 


349 

CHAP.  II. 

Of  Natural  Labour. 

§  1.  STAGES  OF  LABOUR. 

Previous  to  the  accession  of  labour,  we  observe  certain  pre- 
cursory signs,  which  appear  sometimes  for  several  days,  oftener 
only  for  a  few  hours  before  pains  be  felt.  The  uterine  fibres  be- 
gin slowly  and  gradually  to  contract  or  shorten  themselves,  by 
which  the  uterus  becomes  tenser  and  smaller-  It  subsides  in  the 
belly  :  the  woman  feels  as  if  she  carried  the  child  lower  than  for- 
merly, and  thinks  herself  slacker  and  less  than  she  was  before. 
For  some  days  before  gestation  be  completed,  she  in  many  cases 
is  indolent  and  inactive,  but  now  she  often  feels  lighter  and  more 
alert.  At  the  same  time  that  the  uterus  subsides,  the  vagina  and 
os  uteri  are  found  to  secrete  a  quantity  of  glairy  mucus,  rendering 
the  organs  of  generation  moister  than  usual :  and  these  are  some- 
what tumid  and  relaxed,  the  vagina  especially  becoming  softer 
and  more  yielding.  These  changes  are  often  attended  with  a 
slight  irritation  of  the  neighbouring  parts,  producing  an  inclination 
to  go  to  stool,  or  to  make  water  frequently,  and  very  often  griping 
precedes  labour,  or  attends  its  commencement. 

The  intention  of  labour  is,  to  expel  the  child  and  secundines. 
For  this  purpose,  the  first  thing  to  be  done,  is  to  dilate,  to  a  suffici- 
ent degree,  the  os  uteri,  so  that  the  child  may  pass  through  it.  The 
next  point  to  be  gained,  is  the  expulsion  of  the  child  itself :  and 
last  of  all,  the  foetal  appendages  are  to  be  thrown  off.  The  pro- 
cess may  therefore  be  divided  into  three  stages.  The  first  stage  is 
generally  die  most  tedious.  It  is  attended  with  frequent,  but  usu- 
ally short  pains,  which  are  described  as  being  sharp,  and  sometimes 
so  severe,  as  to  be  called  cutting  or  grinding.  They  commonly 
begin  in  the  back,  and  extend  toward  the  pubis  or  top  of  the  thighs  j 
but  there  is,  in  this  respect,  a  great  diversity  with  different  women, 
or  the  same  woman  at  different  times.     Sometimes  the  pain  is  felt 


350 

chiefly  or  entirely  in  the  abdomen,  the  back  being  not  at  all  affect- 
ed during  this  stage  ;  and  it  is  generally  observed,  that  such  pains 
are  not  so  effective  as  those  which  affect  the  back.     Or  the  pain 
produced  by  the  contraction  of  the  womb,  may  be  felt  in  the  ute- 
rine region  ;  and  when  it  goes  off,  may  be  succeeded  by  a  dis- 
tressing aching  in  the  back.     In  other  cases,  the  pain  is  confined 
to  the  small  of  the  back,  and  upper  part  of  the  sacrum  ;  and  is  ei- 
ther of  a  dull  aching  kind,  or  sharp  and  acute,  and  in  some  in- 
stances, is  attended  with  a  considerable  degree  of  sickness,  or  ten- 
dency to  syncope.     The  most  regular  manner  of  attack,  is  for  pains 
to  be  at  first  confined  to  the  back,  descending  lower  by  degrees,  and 
extending  round  to  the  belly,  pubis,  or  top  and  fore  part  of  the 
thighs,  and  gradually  stretching  down  the  back  part  of  the  thighs, 
the  fore  part  becoming  easy  :  occasionally  one  thigh  alone  is  af- 
fected.    At  this  time  also,  one  of  the  legs  is  sometimes  affected 
with  cramp.      The  duration  of  each  pain  is  variable  ;    at  first 
it  is  very  short,  not  lasting  above  half  a  minute,  perhaps  not  so  long, 
but  by  degrees  it  remains  longer,  and  becomes  more  severe.     The 
aggravation,  however,  is  not  uniform,  for  sometimes  in  the  middle 
of  the  stage,  the  pains  are  shorter  and  more  trifling  than  in  the  for- 
mer part  of  it.     During  the  intermission  of  the  pains,  the  woman 
sometimes  is  very  drowsy,  but  at  other  times  is  particularly  irrita- 
ble and  watchful.     The  pains  are  early  attended  with  a  desire  to 
grasp  or  hold  by  the  nearest  object,  and  at  the  same  time,  the 
cheeks  become  flushed,  and  the  colour  increases  with  the  severity 
of  the  pain. 

The  pains  of  labour  often  begin  with  a  considerable  degree  of 
chilness ;  or  an  unusual  shaking  or  trembling  of  the  body,  with  or 
without  a  sensation  of  coldness.  These  tremors  may  take  place, 
however,  at  any  period  of  labour ;  they  may  usher  in  the  second 
stage,  and  be  altogether  wanting  during  the  first ;  or  they  may  not 
appear  at  all,  even  in  the  slightest  degree;  or  they  may  be  present 
only  for  a  very  short  time.  They  do  not  generally  precede  the 
uterine  pain,  but  may  be  almost  synchronous  in  their  attack  :  in 
other  cases  they  do  not  appear  until  the  pain  has  lasted  for  a  short 
space  of  time  ;  but  whenever  they  do  come  on,  it  is  usual  for  the 
uterine  pain  to  be  speedily  removed.     Hence  it  might  be  suppose 


351 

ed  that  they  should  materially  retard  labour,  but  this  is  far  from  be- 
ing always  the  case.  In  degree,  they  vary  from  a  gentle  tremor  to 
a  concussion  of  the  frame,  so  violent  as  to  shake  the  bed  on  which 
the  patient  rests,  and  even  to  bear  some  resemblance  to  a  convul- 
sion. The  stomach  also  sympathizes  with  the  uterus  during  this 
stage,  the  patient  complaining  of  a  sense  of  oppression  ;  sometimes 
of  heartburn  or  sickness,  or  even  of  vomiting,  which  is  considered 
as  a  g;ood  symptom,  when  it  does  not  proceed  from  exhaustion  ; 
or  of  a  feeling  of  sinking  or  faintness,  but  the  pulse  is  generally 
good.  When  there  is  in  a  natural  labour,  a  sudden  attack  of  sick- 
ness, faintishness,  and  feeble  pulse,  the  patient  is  generally  soon 
relieved  by  vomiting  bile.  These  symptoms,  however,  are  often 
wanting,  or  attack  at  different  periods  of  labour  :  like  the  rigours, 
they  may  be  absent  during  the  greatest  part  of  the  first  stage,  or 
until  its  end,  ushering  in  the  second ;  but  in  general,  they  are  con- 
fined to  the  first  stage,  going  off  when  the  os  uteri  is  fully  dilated. 
In  consequence,  partly  of  those  feelings,  partly  of  the  anxiety  and 
solitude  connected  with  a  state  of  suffering  and  danger,  and  partly 
from  the  pains  being  free  from  any  sensation  of  bearing-down,  the 
woman,  during  this  stage,  is  apt  to  become  desponding,  and  some- 
times fretful.  She  supposes  that  the  pains  are  doing  no  good :  that 
she  has  been,  or  is  to  be,  long  in  labour ;  that  something  might  be 
done  to  assist  her,  or  has  been  done,  which  had  better  have  been 
avoided ;  and  that  there  is  a  wrong  position  of  the  child,  or  defi- 
ciency of  her  own  powers. 

When  the  pains  of  labour  begin,  there  is  an  increased  discharge 
of  mucus  from  the  vagina,  which  proceeds  from  the  vaginal  lacu- 
nae, and  from  the  os  uteri.  It  is  glairy,  whitish,  and  possesses  a. 
peculiar  odour.  When  the  os  uteri  is  considerably  dilated,  though 
sometimes  at  an  earlier  period,  there  is,  in  consequence  of  the  se- 
paration of  the  decidua,  a  small  portion  of  blood  discharged,  which 
gives  a  red  tinge  to  the  mucus. 

The  distention  of  the  os  uteri  is  often  attended  with  irritation  of 
the  neighbouring  parts,  the  woman  complaining  of  a  degree  of 
strangury ;  or  having  one  or  two  stools  with  or  without  griping, 
especially  in  the  earlier  part  of  the  stngo.  The  pulse  generally  ft 
somewhat  accelerated. 


352 

The  os  uteri  being  considerably  dilated,  the  second  stage  begins. 
The  pains  become  different,  they  are  felt  lower  down,  they  are 
more  protracted,  and  attended  with  a  sense  of  bearing-down,  or 
an  involuntary  desire  to  expel  or  strain  with  the  muscles  ;  and  this 
desire  is  very  often  accompanied  with  a  strong  inclination  to  go  to 
stool.  A  perspiration  breaks  out,  and  the  pulse,  which,  during  the 
first  stage,  beat  rather  more  frequently  than  usual,  becomes  still 
quicker ;  the  woman  complains  of  being  hot,  and  generally  the  mouth 
is  parched.  Soon  after  the  commencement  of  this  stage,  it  is  usual 
for  the  liquor  amnii  to  be  discharged.  This  is  often  followed  by 
a  short  respite  from  pain,  but  presently  the  efforts  are  redoubled* 
Sometimes  there  is  no  cessation,  but  the  pains  immediately  be- 
come more  severe,  and  sensibly  effective.  The  perinaeum  now 
begins  to  be  pressed  outward,  and  the  labia  are  put  upon  the  stretch. 
The  protrusion  of  the  perinaeum  gradually  increases,  but  it  is  not 
constant :  for  when  the  pain  goes  off,  the  head  generally  recedes, 
a  little,  and  the  perinaeum  is  relaxed.  Presently  the  head  descends 
so  low,  that  the  parts  are  kept  permanently  on  the  stretch,  and  the 
anus  is  carried  forward.  Then  the  vertex  pressing  forward,  the 
labia  are  enlongated,  and  the  orifice  of  the  vagina  dilated.  The 
perinaeum  is  very  thin,  much  stretched,  and  spread  over  the  head 
of  the  child.  As  the  head  passes  out,  the  perinaeum  goes  back 
over  the  forehead,  becoming  narrower,  but  still  more  distended  la- 
terally. If  the  perinaeum  did  not  move  backward,  as  the  head 
moved  forward,  it  would  run  a  greater  risk  of  being  torn ;  and  in- 
deed even  in  the  most  regularly  conducted  labour,  a  part  of  it  is 
often  rent.  Delivery  of  the  head  is  accomplished  with  very  se- 
vere suffering  ;  but  immediately  afterwards,  the  woman  feels  easy, 
and  free  from  pain.  In  a  very  little  time,  however,  the  uterus 
again  acts,  and  the  rest  of  the  child  is  expelled,  which  completes 
the  second  stage  of  labour.  The  expulsion  of  the  body  is  gener- 
ally accomplished  very  easily,  and  quickly ;  but  sometimes  the 
woman  suffers  several  strong  and  forcing  pains,  before  the  shoul- 
ders are  expelled.  The  birth  of  the  child  is  succeeded,  after  a 
short  calm,  by  a  very  slight  degree  of  pain,  which  is  consequent 
to  that  contraction  which  is  necessary  for  the  expulsion  of  the  pla* 
centa.     This  expulsion  is  accompanied  and  preceded  by  a  slight 


353 

discharge  of  blood,  which  is  continued,  but  in  decreasing  quantrtv, 
for  a  few  days,  under  the  name  of  the  red  lochia. 

§  2.  DURATION  OF  THE  PROCESS. 

The  duration  of  this  process,  and  of  its  stages,  varies  not  only 
in  different  women,  but  in  the  same  individual  in  successive  la- 
bours ;  for  although  some,  without  any  mechanical  cause,  be  uni- 
formly slow  or  expeditious,  others  are  tedious  in  one  labour,  and 
perhaps  extremely  quick  in  the  next,  and  this  variation  cannot  be 
foreseen  from  any  previous  state  of  the  system.  A  natural  labour 
ought  to  be  finished  within  24  hours  after  the  first  attack  of  pain, 
provided  the  pains  be  truly  uterine,  and  are  continued  regularly  ; 
for  occasionally,  after  being  repeated  two  or  three  times,  they  be- 
come suspended,  and  the  person  keeps  well  for  many  hours,  aftet 
which  the  process  begins  properly.  In  such  cases,  the  labour  can- 
not be  dated  from  the  first  sensation  of  pain,  nor  deemed  tedious. 
The  greatest  number  of  women  do  not  complain  for  more  than  12 
hours ;  many  for  a  much  shorter  period  ;  and  some  for  not  more 
than  one  hour.  Few  women  call  the  accoucheur,  until,  from  the 
regularity  and  frequency  of  the  pains,  they  are  sure  that  they  are 
in  labour,  and  feel  themselves  becoming  worse.  As  the  celerity 
of  the  process  cannot  be  previously  determined,  many  women  thus 
bear  their  children  alone,  becoming  rapidly  and  unexpectedly  - 
worse.  On  au  average,  it  will  be  found,  that  in  natural  labour,  the 
accoucheur  is  not  called  above  four  hours  previous  to  delivery. 

The  regularity  and  comparative  length  of  the  different  stages  ia 
also  various ;  but  it  will  be  generally  observed,  that  when  the  wo- 
man has  a  natural  labour  protracted  to  its  utmost  extent,  the  delay 
takes  place  in  the  first  stage ;  and  in  those  cases  where  the  second 
stage  is  protracted,  the  delay  occurs  in  the  latter  end  of  that  stage. 
In  most  cases,  the  first  stage  is  triple  the  length  of  the  second.  The 
first  stage  may  be  tedious,  from  the  pains  not  acting  freely  on  the 
os  uteri,  or  being  weak  and  inadequate  to  the  effect  intended,  or 
becoming  prematurely  blended  with  the  second  stage  j  that  is  to 
-ay,. bearing-down  efforts  being  made,  before  the  os  uteri  be  much 

46 


354 

dilated.  Various  circumstances  may  conspire  to  produce  this  de- 
lay, such  as  debility  of  the  uterus,  rigidity  of  its  mouth,  premature 
evacuation  of  the  water,  improper  irritation,  injudicious  voluntary 
efforts,  &c.  The  second  stage  may  be  tedious,  from  irregularity 
of  the  uterine  contraction,  or  from  a  suspension  of  the  bearing-down 
efforts,  or  from  the  head  not  turning  into  the  most  favourable  di- 
rection, or  from  the  rigidity  of  the  external  organs. 

These,  and  other  causes,  which  will  hereafter  be  considered, 
may  not  only  protract  the  labour,  but  may  even  render  it  so  tedi- 
ous, as  to  remove  it  from  the  class  of  natural  labours  altogether.  It 
is  a  general  opinion,  that  a  first  labour  is  always  more  lingering  than 
those  which  succeed.  We  should  be  led,  however,  to  suppose, 
that  parturition,  being  a  natural  function,  ought  to  be  as  well  and  as 
easily  performed  the  first  time,  as  the  fifth;  the  process  not  depend- 
ing upon  either  habit  or  instruction.  But  we  do  find,  that  here,  as 
in  many  other  cases,  popular  opinion  is  founded  on  fact ;  for  al- 
though, in  several  instances,  a  first  labour  is  as  quick  as  a  second, 
yet,  in  general,  it  is  longer  in  both  its  stages.  This,  perhaps,  depends 
chiefly  on  the  facility  with  which  the  different  soft  parts  dilate, 
after  they  have  been  once  fully  distended.  Some  have  attributed 
the  pain  of  parturition  to  mechanical  causes,  ascribing  it  to  the 
shape  of  the  pelvis,  and  the  size  of  the  child's  head.  But  this  is 
not  the  case,  for  in  a  great  majority  of  cases,  the  pelvis  is  so  pro- 
portioned, as  to  permit  the  head  to  pass  with  great  facility.  The 
pain  and  difficulty  attending  the  expulsion  of  the  child  in  natural 
labour,  are  to  be  attributed  to  the  forcible  contraction  of  the 
sensible  fibres  of  the  uterus,  and  to  the  dilatation  of  the  os  uteri  and 
vulva,  in  consequence  thereof.  Women  will  therefore,  ceteris  pa- 
ribus, suffer  in  proportion  to  the  sensibility  of  the  organs  concerned, 
and  the  difficulty  with  which  the  parts  dilate.  In  proportion  as  we 
remove  women  from  a  state  of  simplicity  to  luxury  and  refinement, 
we  find  that  the  powers  of  the  system  become  impaired,  and  the 
process  of  parturition  is  rendered  more  painful.  In  a  state  of  na- 
tural simplicity,  women,  in  all  climates,  bear  their  children  easily., 
and  recover  speedily;*  but  this  is  more  especially  the  case  in  those 

*  "  The  Greenlanders,  mostly,  do  all  their  common  business  just  before  and 


355 

countries  where  heat  conspires  to  relax  the  fibres.  The  quality  or 
quantity  of  the  food  lias  much  less  influence  than  the  general  habit 
of  life,  upon  the  process  of  parturition.  In  a  savage  state,  women, 
though  living  abstemiously,  and  often  compelled  to  work  more  than 
men,  bear  children  with  facility ;  whilst  in  this  country,  women 
who  live  on  plain  diet  arc  not  easier  than  those  who  indulge  in  rich 
viands. 

§  3.  OF  EXAMINATION. 

The  existence  and  progress  of  labour,  and  the  manner  in  which 

"  after  their  delivery ;  and  a  still-born  or  deformed  child  is  seldom  heard  of." 
Crantz's  History  of  Greenland,  Vol.  I.  p.  161. 

Long  tells  us,  that  the  American  Indians,  as  soon  as  they  bear  a  child,  go  into 
the  water  and  immerse  it.  One  evening  he  asked  an  Indian  where  his  wife  was ; 
"  he  supposed  she  had  gone  into  the  woods,  to  set  a  collar  for  a  partridge."  In 
about  an  hour  she  returned  with  a  new-born  infant  in  her  arms,  and  coming  up 
to  me,  said,  in  Chippoway,  "  Oway  saggonash  payshik  shomagonish ;"  or,  "  Here, 
"  Englishman,  is  a  young  warrior."     Travels,  p.  59. 

"  Comme  les  accouchemens  sont  tres-aise"s  en  Perse,  de  meme  que  dans  les 
"  autres  pais  chauds  de  1' Orient,  il  n'y  a  point  de  sages  femmes.  Les  parentes 
"  agees  et  les  plus  graves,  font  cet  office,  mais  comme  il  n'y  a  gueres  de  vieilles 
"  matrones  dans  le  harm,  on  en  fait  venir  dehors  dans  le  besoin."  Voyages  de 
M.  Chardin,  Tom.  VI.  p.  230. 

Lempriere  says,  "  Women  in  this  country  (Morocco,)  suffer  but  little  incon- 
"  venience  from  child-bearing.  They  are  frequently  up  next  day,  and  go  through 
u  all  the  duties  of  the  house  with  the  infant  on  their  back."    Tour,  p.  328. 

Winterbottom  says,  that,  "  with  the  Africans,  the  labour  is  very  easy,  and  trust- 
"  ed  solely  to  nature,  nobody  knowing  of  it  till  the  woman  appears  at  the  door  of 
"  the  hut  with  the  child."     Account  of  Native  Africans,  &c.  Vol.  II.  p.  209. 

The  Snangalla  women  "  bring  forth  children  with  the  utmost  ease,  and  never 
"  rest  or  confine  themselves  after  delivery  j  but  washing  themselves  and  the  child 
"  with  cold  water,  they  wrap  it  up  in  a  soft  cloth,  made  of  the  bark  of  trees,  and 
"  hang  it  up  on  a  branch,  that  the  large  ants  with  which  they  are  infested,  and 
«« the  serpents  may  not  devour  it."    Bruce's  Travels,  Vol  II.  p.  553. 

In  Otaheite,  New  South  Wales,  Surinam,  &c.  parturition  is  very  easy,  and 
many  more  instances  might,  if  necessary,  be  adduced.  We  are  not,  however,  to 
suppose  that  in  warm  climates  women  do  not  sometimes  suffer  materially.  In 
the  East  Indies,  "  many  of  the  women  lose  their  lives  the  first  time  they  bring 
"  forth."     Bartolomeo's  Voyage,  chap.  11. 

Undomesticated  animals  generally  bring  forth  their  young  with  considerable 
case  ;  but  sometimes  they  suffer  much  pain,  and,  when  domesticated,  occasionally 
lose  their  lives. 


356 

the  child  is  placed,  are  ascertained  by  examination  per  vaginam. 
For  this  purpose  the  woman  ought  to  be  placed  in  bed,  on  her  felt 
side,*  with  a  counterpane  thrown  over  her,  if  she  be  not  undressed. 
The  hand  is  to  be  passed  along  the  back  part  of  the  thighs  to  the 
perinaeum,  and  thence  immediately  to  the  vagina,  into  which  the 
fore  finger  is  to  be  introduced.  It  never  ought  to  be  carried  to 
the  fore  part  of  the  vulva,  and  from  that  back  to  the  vagina.  The 
introduction  is  to  be  accomplished  as  speedily  and  gently  as  pos- 
sible, and  the  greatest  delicacy  must  be  observed.  The  informa- 
tion which  we  wish  to  procure  is  then  to  be  obtained  by  a  very 
perfect,  but  very  cautious  examination  of  the  os  uteri  and  present- 
ing part  of  the  child,  which  gives  no  pain,  and  consequently 
removes  the  dread  which  many  women,  either  from  some  mis- 
conception, or  from  previous  harsh  treatment,  entertain  of  this 
operation.  The  application  of  the  hand  to  the  abdomen,  during 
the  continuance  of  the  pain,  may  ascertain,  from  the  temporary 
hardness  of  the  uterus,  that  its  fibres  are  contracting  universally  .f 

When  a  woman  is  in  labour,  we  should,  if  the  pains  be  regular, 
propose  an  examination  very  soon  after  our  arrival. 

It  is  of  importance  that  the  situation  of  the  child  be  early  ascer- 
tained, and  most  women  are  anxious  to  know  what  progress  they 
have  made,  and  if  their  condition  be  safe.  As  it  is  usual  to  ex- 
amine during  a  pain,  many  have  called  this  operation  "  taking  a 
pain ;"  but  there  is  no  necessity  for  giving  directions  respecting 
the  proper  language  to  be  used,  as  every  man  of  sense  and  deli- 
cacy will  know  how  to  behave,  and  can  easily,  through  the  medium 
of  the  nurse,  or  by  turning  the  conversation  to  the  state  of  the 
patient,  propose  ascertaining  the  progress  of  the  labour.  Some 
women,  from  motives  of  false  delicacy,  and  from  not  understand- 
ing the  importance  of  procuring  early  information  of  their  condition, 


*  A  standing  or  half-sitting  position  has  been  proposed  by  some,  and  may 
doubtless,  in  certain  diseases  of  the  uterus,  be  proper,  that  it  may,  by  its  weight, 
come  within  reach.  Sometimes  in  the  early  months  of  pregnancy,  it  is  allowable 
from  the  same  motives;  but,  during  labour,  it  is  not  often  that  the  uterus  is  so 
high  that  the  examination  cannot  be  performed  in  a  recumbent  posture. 

1  This  mark  has  been  properly  insisted  on  by  Mr.  Power,  in  his  ingenious 
Treatise  on  Midwifery,  p.  25. 


357 

arc  averse  from  examination,  until  the  pains  become  severe.  But 
this  delay  is  very  improper;  for,  should  the  presentation  require 
any  alteration,  this  is  easier  effected  before  the  membranes  burst, 
than  afterwards.  When  the  presentation  is  ascertained  to  be  natu- 
ral, there  is  no  occasion  for  repeated  examinations  in  the  first  stage, 
as  this  may  prove  a  source  of  irritation,  and,  should  the  stage  be 
tedious,  may  be  a  mean  of  exciting  impatience.  In  the  second 
stage,  the  frequency  of  examination  must  be  proportioned  to  the 
rapidity  of  the  process. 

In  order" to  avoid  pain  and  irritation,  it  is  customary  to  anoint 
the  finger  with  oil  or  pomatum  ;  but  unless  this  practice  be  used 
as  a  precaution  to  prevent  the  action  of  morbid  matter  on  the 
skin,  it  is  not  very  requisite,  the  parts  being,  in  labour,  generally 
supplied  with  a  copious  secretion  of  mucus.  It  is  usual  for  the 
room  to  be  darkened,  and  the  bed  curtains  drawn  close,  during  an 
examination ;  and  the  hand  should  be  wiped  with  a  towel,  under 
the  bed-clothes,  before  it  be  withdrawn.  The  proper  time  for  ex- 
amining is  during  a  pain ;  and  we  should  begin  whenever  the  pain 
comes  on.  We  thus  ascertain  the  effect  produced  on  the  os  uteri, 
and  by  retaining  the  finger  until  the  pain  goes  off,  we  determine 
the  degree  to  which  the  os  uteri  collapses,  and  the  precise  situation 
of  the  presenting  part,  which  we  cannot  do  during  a  pain,  if  the 
membranes  be  still  entire,  lest  the  pressure  of  the  finger  should,, 
were  they  thin,  prematurely  rupture  them. 

An  examination  should  never,  if  possible,  be  proposed  or  made 
whilst  an  unmarried  lady  is  in  the  room,  but  it  is  always  proper 
that  the  nurse  or  some  other  matron  be  present. 

The  existence  of  labour  is  ascertained  by  the  effects  of  the  pains 
on  the  os  uteri ;  and  its  progress,  by  the  degree  to  which  it  is  di- 
lated, and  the  position  of  the  head  with  regard  to  different  parts  of 
the  pelvis. 

Before  labour  begins,  the  os  uteri  is  generally  closed,  and  direct- 
ed backwards  towards  the  sacrum.  When  we  examine  in  the  com- 
mencement of  labour,  the  os  uteri  is  to  be  sought  for  near  the  sa- 
crum, at  the  back  part  of  the  pelvis,  whilst  between  that  spot  and 
the  pubis,  we  can  pass  the  finger  along  the  fore  part  of  the  cervix 
uteri.     On  this,  the  presenting  part  of  the  child  rests,  so  that,  in 


358 

natural  labour,  it  assumes  somewhat  the  shape  of  the  head  ;  and, 
for  the  sake  of  distinction,  I  shall  call  it  the  uterine  tumour.  In 
some,  it  is  so  firmly  applied  to  the  head,  and  so  tense,  that  a  su- 
perficial observer  would  take  it  for  the  head  itself.  In  this  case 
the  labour  often  is  lingering.  This  tumour,  or  portion  of  the  ute- 
rus, is  broad  in  the  beginning  of  labour,  but  becomes  narrower  as 
the  os  uteri  dilates,  until  at  last  it  is  completely  effaced,  the  head, 
cither  naked  or  covered  with  the  membranes,  occupying  the  vagi- 
na. The  breadth  of  this  portion  of  the  uterus,  therefore,  as  well 
as  the  examination  of  the  os  uteri,  will  serve  to  ascertain  the  state 
of  the  labour. 

The  os  uteri  gradually  dilates  by  the  pains  of  labour,  but  this 
dilatation  is  easier  effected  in  some  cases  than  in  others.  In  some, 
though  the  pains  have  lasted  for  many  hours,  and  have  been  fre- 
quent, the  os  uteri  will  be  found  still  very  little  opened.  In  others, 
a  very  great  effect  is  produced  in  a  short  time ;  nay,  we  even  find, 
that  the  os  uteri  may  be  partly  dilated  without  any  pain  at  all. 
We  cannot  exactly  foretell  the  effect  which  the  pains  may  have  by 
any  general  rule. 

We  find,  in  different  women,  the  os  uteri  in  very  opposite  states. 
In  some  it  is  thick,  soft,  and  protuberant ;  in  others,  thin  and  tu- 
bulated ;  sometimes  it  is  not  prominent,  but  the  edges  of  the  mouth 
are  on  the  same  plane,  like  the  mouth  of  a  purse  :  these  edges 
may  be  thin  or  thick,  and  both  these  states  may  exist  with  hard- 
ness or  softness  of  the  fibre.  In  some  cases,  they  seem  to  be 
swelled,  as  if  they  were  cedematous,  and  this  state  is  often  com- 
bined with  oedema  of  the  vulva,  or  it  may  proceed  from  ecchy- 
mosis.  Now,  of  these  conditions,  some  are  more  favourable  than 
others  ;  a  rigid  os  uteri,  with  the  lips  either  flat  or  prominent,  is 
generally  a  mark  of  slow  labour  ;  for  as  long  as  this  state  conti- 
nues, dilatation  is  tardy  ;  a  thick -cedematous  feel  of  the  os  uteri  is 
also  unfavourable ;  and  usually  a  projecting  or  tubulated  mouth, 
especially  if  the  margin  be  thick  and  hard,*  is  connected  with  a 
more  tedious  labour  than  where  the  os  uteri  is  flat.     In  some  cases 

*  If  the  margin  be  thin  and  soft,  the  os  uteri  sometimes,  in  the  course  of  an 
hour,  loses  its  projecting  form,  and  becomes  considerably  dilated. 


359 

of  slow  labour,  the  os  uteri,  for  many  hours,  is  scarcely  discerni- 
ble, resembling  a  dimple  or  small  hard  ring,  perfectly  level  with 
the  rest  of  the  uterus.  But  although  these  observations  may  as- 
sist the  prognosis,  yet  we  never  can  form  an  opinion  perfectly  cor- 
rect ;  for  a  state  of  the  os  uteri,  apparently  unfavourable,  may  be 
speedily  exchanged  for  one  very  much  the  reverse,  and  the  labour 
may  be  accomplished  with  unexpected  celerity.  Our  prognosis, 
therefore,  should  be  very  guarded.  When  the  pains  produce  lit- 
tle apparent  effect  on  the  os  uteri ;  when  they  are  slight  and  few ; 
and  when  the  orifice  of  the  uterus  is  hard  and  rigid,  or  thick  and 
puckered  during  a  pain  ;  there  is  much  ground  to  expect  that  the 
labour  may  be  lingering.  On  the  other  hand,  when  the  pains  are 
brisk,  the  os  uteri  thin  and  soft,  we  may  expect  a  more  speedy 
delivery  ;  but  as  in  the  first  case,  the  unfavourable  state  of  the  os 
uteri  may  be  unexpectedly  removed,  so  in  the  second,  the  pain- 
may  become  suspended  or  irregular,  and  disappoint  our  hopes. 
The  os  uteri  seldom  dilates  equalljvin  given  times,  but  is  more 
slow  at  first  in  opening  than  afterwards.  It  has  been  supposed, 
that  if  it  require  three  hours  to  dilate  the  os  uteri  one  inch,  it  will 
require  two  to  dilate  it  another  inch,  and  other  three  to  dilate  it 
completely.  This  calculation,  however,  is  subject  to  great  varia- 
tion, for  iu  many  cases,  though  it  require  four  hours  to  dilate  the 
os  uteri  one  inch,  a  single  hour  more  may  be  sufficient  to  finish 
the  whole  process. 

The  os  uteri  is,  in  the  beginning  of  labour,  generally  pretty  high 
up ;  btit  as  the  process  advances,  the  uterus  descends  in  the  pelvis, 
along  with  the  head  ;  and,  in  proportion  as  it  descends,  the  os  uteri, 
dilates,  whilst  the  uterine  tumour  diminishes  in  breadth.  Should 
the  os  uteri  remain  long  high,  even  although  it  be  considerably  di- 
lated, but  more  especially  if  it  be  not,  there  is  reason  to  suppose 
that  the  labour  shall  be  continued  still  for  some  time.  On  the 
other  hand,  should  the  uterus  descend  too  rapidly,  there  may  be  a 
species  of  prolapsus  induced,  the  os  uteri  appearing  at  the  orifice 
of  the  vagina.  This  state  is  generally  attended  with  premature 
bearing-down  pains,  and  indicates  a  painful,  and  rather  tediou- 
labour. 

The  protrusion  of  the  membranes,  and  discharge  of  the  liquor 


360 

amnii,  ought  to  bear  a  certain  relation  to  the  advancement  of  labour. 
Whilst  the  os  uteri  is  beginning  to  dilate,  the  membranes  have  little 
tension ;  they  scarcely  protrude  through  the  os  uteri,  until  it  be 
considerably  opened.     But  in  proportion  as  the  dilatation  advances, 
and  the  pains  become  of  the  pressing  kind,  the  membranes  are  ren- 
dered more  tense,  protruding  during  a  pain,  and  becoming  slack, 
and  receding  when  it  goes  off.     In  some  cases,  by  examination, 
we  find  the  membranes  forced  out  very  low  into  the  vagina,  like  a 
portion  of  a  bladder,  tense  and  firm  during  a  pain,  but  disappearing 
in  its  absence.     Sometimes,  although  the  head  be  so  high  as  not 
to  touch  the  perineum,  the  membranes  protrude  the  perineum, 
and  the  fasces  are  evacuated  or  pressed  out,  as  if  the  head  were 
about  to  be  expelled.     When  the  membranes  burst,  the  head  is  in 
such  cases  often  delivered  in  a  few  seconds  ;  but  the  pains  may 
remit  for  a  short  time,  and  the  woman  be  easier  than  formerly.   The 
protrusion  of  the  membranes,  which  has  been  described  by  some 
as  constituting  a  part  of  a  natural  labour,  is  by  no  means  a  univer- 
sal occurrence  ;  for  in  numerous  instances  the  membranes  protrude 
very  little,  and  scarcely  form  a  perceptible  bag  in  the  vagina. 
When  the  pains  have  acted  some  time  on  the  membranes,  pushing 
the  liquor  amnii  -against  them,  and  especially  when  they  become 
pressing,  the  membranes  burst  and  the  water  escapes,  sometimes 
in  a  considerable  quantity ;  but  in  other  cases,  very  little  comes 
away,  the  head  occupying  the  pelvis  so  completely,  that  most  of 
the  water  is  retained  above  it,  and  is  not  discharged  until  the  child 
be  born.     If  there  be  great  irregularity  in  the  degree  to  which  the 
membranes  protrude,  there  is  no  less  in  the  period  at  which  they 
break.     In  some  cases,  from  natural  feebleness  or  thinness,  they 
break  very  early,  and  the  liquor  amnii  comes  away  slowly.    Some- 
times they  break  in  the  middle  or  latter -end  of  the  first  stage,  in 
the  commencement  of  the  second,  or  not  until  the  very  end,  when 
the  head  is  about  to  be  born.     The  opening  is  sometimes  very 
large,  and  the  head  enlarging  it,  passes  through  it ;  at  other  times 
it  is  small,  and  the  membranes  are  not  perforated  by  the  head,  but 
they  come  along  with  it  like  a  cap  or  cover.     By  examination,  wc 
ascertain  the  state  of  the  membranes,   and  maybe  assisted  in  our 
judgment  of  the  progress  of  the  labour.     When  the  membranes  feel 


361 

tense,  and  are  protruded  during  a  pain,  we  may  be  sure  that  the 
action  of  the  uterus  is  brisk  and  good.  When  much  water  is  col- 
lected beneath  the  head,  forming  a  pretty  large  bag  in  the  vagina ; 
or  when,  during  the  pain,  there  is  a  tense  protrusion  of  the  mem- 
branes, though  they  be  flat,  forming  a  small  segment  of  a  large  cir- 
cle, we  may  expect,  that  if  the  pains  continue  as  they  promise  to 
do,  the  membranes  will  soon  burst,  and  the  pains  become  more 
pressing.  If  during  each  pain,  after  the  rupture,  a  quantity  of 
water  come  away,  it  is  probable,  that  whenever  the  uterus  is  pretty 
well  emptied  of  the  fluid,  it  will  contract  more  powerfully.  Should 
the  membranes  break  when  the  os  uteri  is  not  fully  opened,  per- 
haps only  half  dilated,  we  may,  if  there  be  a  large  discharge,  ex- 
pect a  brisker  action,  and  that  the  full  dilatation  of  the  os  uteri 
will  be  soon  accomplished ;  but  if  the  water  only  ooze  away,  and 
the  pains  become  less  frequent,  and  not  more  severe,  the  labour 
may  probably  be  protracted  for  some  time. 

In  the  first  stage  of  labour,  the  head  will  be  found  placed  ob- 
liquely along  the  upper  part  of  the  pelvis,  with  the  vertex  directed 
toward  one  of  the  acetabula.  The  finger  can  easily  ascertain  the 
sagittal,  and  afterwards  the  lambdoidal  suture ;  the  central  portion 
of  the  sagittal  suture  is  the  point  from  which  we  set  out,  and,  if  the 
finger  be  readily  led  to  the  angle  formed  by  the  posterior  edges  of 
the  parietal  bones,  we  may  be  sure  that  the  presentation  is  favour- 
able. If,  on  the  other  hand,  we  can  feel  the  anterior  fontanelle, 
the  vertex  is  generally  directed  to  the  sacro-iliac  articulation. 
When  the  pelvis  is  well  formed,  and  the  cranium  of  due  size,  the 
head  may  commonly  be  felt  in  every  stage  of  labour ;  but  there 
are  cases,  in  which,  even  although  the  pelvis  be  ample,  it  is  not 
easily  touched  for  some  time.  Such  instances,  however,  are  rare ; 
and  whenever  we  are  long  of  feeling  the  presentation,  and  do  not 
discover  a  round  uterine  tumour,  we  may  suspect  that  some  other 
part  of  the  child  than  the  head  presents.  Even  in  the  end  of 
pregnancy,  and  long  before  labour  begins,  the  head  can  usually  be 
discovered  resting  on  the  distended  cervix  uteri ;  but  different  cir- 
cumstances may  for  a  time  prevent  it  from  being  felt ;  the  head 
perhaps  in  some  cases,  as  from  a  fall  for  instance,  being  for  a  ghort 
time  displaced  towards  one  side. 

47 


362 


In  proportion  as  the  head  descends  in  the  pelvis,  the  vertex  is 
turned  forward ;  so  that,  when  the  whole  head  has  entered  the 
pelvis,  the  face  is  thrown  into  the  hollow  of  the  sacrum,  and  the 
sagittal  suture  rests  on  the  perineum,  whilst  the  occiput  is  placed 
under  the  symphysis  pubis,  or  on  its  inside.  This  takes  place 
earlier  in  one  case  than  in  another. 

When  the  head  comes  to  present  at  the  orifice  of  the  vagina,  or 
passes  a  line  drawn  from  the  under  edge  of  the  symphysis  pubis 
back  to  the  sacrum,  the  perineum  and  skin  near  the  tuberosities  of 
the  ischia  become  full,  as  if  swelled,  but  not  tense.  This  at  first 
proceeds  from  relaxation  of  the  muscles,  and  some  degree  of  descent 
of  the  vagina  and  rectum.  Whenever  this  is  felt,  we  may  be  sure 
that  the  head  is  descending  ;  but  although  a  few  pains  may  dis- 
tend the  perineum,  it  may  yet  be  some  hours  before  this  take 
place,  the  pains  for  all  that  time  appearing  to  produce  very  little 
effect,  although  the  pelvis  be  well  formed.  Should  the  perineum 
become  stretched,  and  the  anus  be  carried  forward  a  little  during 
the  pain,  we  may  expect  that  delivery  is  at  hand.  If  the  woman 
have  already  borne  children,  the  child  is  sometimes  delivered  within 
a  few  minutes  after  the  perineum  is  first  felt  to  become  full. 

When  the  pelvis  is  well  formed,  the  head  generally  descends 
without  much  change  of  the  scalp ;  but  when  it  is  contracted,  or 
the  head  rests  long  on  the  perineum,  the  scalp  is  either  wrinkled, 
or  protruded  like  a  tumour  filled  with  blood. 

By  examination,  we  ascertain  the  presentation,  and  the  progress 
which  the  labour  has  made  ;  but  in  forming  an  opinion  respecting 
the  probable  duration  of  the  process,  we  must  be  greatly  influenced 
by  the  state  of  the  pains,  and  in  part  also  by  our  knowledge  of 
former  labours,  if  the  woman  have  borne  many  children.  The 
different  stages  of  labour  are  generally  marked  by  a  different  mode 
of  expressing  pain.  In  the  first  stage,  the  pains  are  sharp,  and 
the  woman  either  moans  or  frets,  or  sometimes  bears  in  silence. 
The  second  stage  is  marked  by  a  sound,  indicating  a  straining  ex- 
ertion, a  kind  of  protracted  groan,  so  that,  by  the  change  of  the 
cry,  a  practitioner  may  often  determine  the  stage  of  the  labour. 
Sometimes  in  this  stage,  the  woman  clinches  her  teeth,  or  holds  in 
her  breath,  so  that  she  is  scarcely  heard  to  complain.     In  the 


363 

moment  of  expelling  the  head,  some  women  are  quite  silent,  ui 
utter  a  low  groan,  others  scream  aloud.  When  the  pains  in  the 
first  stage  are  increasing  in  frequency,  in  severity,  and  in  dura- 
tion, and  when  they  are  accompanied  with  a  corresponding  dilata- 
tion of  the  os  uteri,  and  especially  when  it,  together  with  the  head, 
gradually  descends,  the  prognosis  is  very  favourable.  When  the 
pains,  after  the  os  uteri  is  considerably  dilated,  become  forcing, 
with  an  inclination  to  void  the  urine  or  faeces,  and  when  these  pains 
are  accompanied  with  a  full  dilatation  of  the  os  uteri,  the  head  at 
the  same  time  descending  lower,  and  the  cervix  beginning  to  turn 
round,  we  may  look  for  a  speedy  delivery.  But  if  the  pains  in  the 
first  stage  be  weak  and  few,  and  occur  at  long  intervals,  or,  though 
not  unfrequent,  if  they  last  only  for  a  few  seconds,  and  especially, 
if  at  the  same  time  the  os  uteri  be  high  up,  or  hard,  or  thick,  we 
may  conclude  that  the  process  is  not  likely  to  be  rapid.  If,  when 
the  os  uteri  is  little  dilated,  there  be  an  inclination  to  bear  down, 
the  labour  is  generally  slow,  and  hence  all  attempts  to  press  with 
the  abdominal  muscles  are  improper ;  for  whether  these  be  made 
voluntarily  or  involuntarily,  they,  during  this  stage,  add  to  the 
suffering,  fatigue  the  woman,  produce  a  tendency  to  prolapsus  uteri, 
so  that,  in  some  instances,  the  os  uteri  is  forced  to  the  orifice  of 
the  vagina,  and  render  the  labour  always  slow  and  severe. 

When  the  head  is  brought  so  low  as  to  protrude  the  perineum, 
the  pains  generally  become  more  frequent  and  severe,  and  very 
soon  effect  the  expulsion.  But  if  they  be  forcing,  and  propel  the 
head  considerably  each  time,  but  it  recedes  completely  thereafter, 
it  is  likely  that  the  delivery  of  the  head  will  be  difficult  and  pain- 
ful ;  for  in  some  cases  the  external  parts  are  long  of  yielding,  and 
require  repeated  efforts  to  distend  them  before  the  head  can  safely 
be  expelled. 

Sometimes  the  pains,  after  beginning  regularly  and  briskly,  be- 
come suspended,  or  less  effective,  and  this  alteration  cannot  be 
foreseen.  It  is  a  popular  opinion,  that  if  a  woman  be  not  delivered 
within  twelve  hours  after  she  is  taken  ill,  the  labour  will  become 
brisker  at  the  same  hour  at  which  it  began,  that  is  to  say,  twelve 
hours  after  its  commencement;  and  this  opinion  is,  in  many  in- 
stances, countenanced  by  fact.  In  other  cases,  the  labour  becomes 


364 

decidedly  brisker  six  hours  after  its  commencement.  Most  women 
begin  to  complain  during  the  night,  or  early  in  the  morning,  and  a 
great  majority  are  delivered  betwixt  twelve  at  night  and  twelve 
o'clock  noon. 


§  4.  CAUSES  OF  LABOUR. 

Different  attempts  have  been  made  to  explain  why  labour  com- 
menced at  the  end  of  the  ninth  month  of  pregnancy.    The  myste- 
rious power  of  numbers,  the  influence  of  the  planets,  the  distention 
of  the  uterine  fibres,  the  pressure  of  the  child  upon  the  developed 
cervix  and  os  uteri,  have  all  in  succession  been  enumerated,  as  af- 
fording a  solution  of  the  question.     It  can  serve  no  good  purpose 
to  enter  into  the  investigation,  for  the  purpose  of  refuting  diese 
opinions,  which  might  be  easily  done,  especially  as  I  have  no  sa- 
tisfactory explanation  to  offer.     We  know,  that  whenever  the  pro- 
cess of  utero-gestation  is  completed,  the  womb  begins  to  contract. 
If,  by  any  means,  this  process  could  be  protracted,  then  labour 
would  be  kept  off;  and,  on  the  other  hand,  if  this  process  be 
stopped  prematurely,  either  from  some  peculiarity  connected  with 
it,  by  which  it  is  completed  earlier  than  usual,  or,  from  being  in- 
terrupted by  extraneous  causes,  acting  either  on  the  uterus,  or  by 
killing  the  child,  then  contraction  does  very  soon  commence.  The 
immediate  cause  of  the  delivery  of  the  child  has  been  attributed  to 
efforts  made  by  the  foetus  ilself,  the  expulsive  force  of  the  abdo- 
minal muscles,  or  the  contraction  of  the  uterus.     The  first  is  fully 
set  aside,  by  our  finding,  that  the  foetus,  when  dead,  is  born  ceteris 
paribus,  as  easily  as  when  it  is  alive  and  active.  That  the  muscles 
alone  cause  the  expulsion  of  the  child,  is  disproved,  by  observing, 
that  in  the  early  part  of  labour  they  are  perfectly  quiescent,  and  no 
voluntary  effort  made  with  them  is  attended  with  any  good  effect. 
That  the  delivery  is  in  a  great  measure  owing  to  the  action  of  the 
uterus,  is  proved  by  observing,  that  the  uterus  contracts  in  propor- 
tion as  the  delivery  advances,  and  when  the  child  is  born,  it  is 
found  to  be  very  greatly  diminished  in  size.     But  we  have  a  still 
more  positive  proof  of  this,  in  attempting  to  turn  the  child,  for  we 


365 

then  feel  very  powerfully  the  action  of  the  uterus,  and  the  efforts 
which  it  makes  to  expel  its  contents.  It  is  not  just,  however,  to 
consider  the  action  of  the  womb  itself,  as  the  sole  agent  in  partu- 
rition ;  for  in  the  second  stage,  the  abdominal  muscles  do  assist  in 
the  expulsion,  not  only  by  supporting  the  uterus,  and  thus  enabling 
it  to  contract  better,  but  also  directly,  by  endeavouring  to  force  the 
uterus,  and  consequently  its  contents,  down  through  the  pelvis. 
Two  purposes  are  intended  by  the  uterine  action ;  the  first  is  to 
open  the  os  uteri,  the  second  to  propel  the  foetus  through  it.  Whilst, 
then,  the  fibres  of  the  uterus  itself  contract,  those  of  the  os  uteri 
must  relax  and  dilate,  and  in  proportion  as  the  foetus  advances 
through  the  pelvis,  the  uterine  fibres  must  shorten  themselves. 
Thus  the  uterine  cavity  is  gradually  diminished,  so  that  the  pla- 
centa can  very  easily,  by  a  continuation  of  the  same  process,  be 
thrown  off;  and  the  uterine  vessels  having  their  diameter  greatly 
lessened,  hemorrhage  is  prevented  after  the  separation  of  the  pla- 
centa. There  are  then  two  processes  taking  place  during  parturi- 
tion, contraction  and  relaxation,  and  these  are  in  natural  labour 
proportionate  to  each  other.  As  the  os  uteri  relaxes,  the  rest  of  the 
uterus  increases  in  the  activity  of  its  contraction.  This  fact,  I  fear, 
has  not  been  sufficiently  attended  to,  and  a  very  great  mistake  has 
often  been  made  in  supposing  that  there  is  greatest  contractive  or 
expulsive  effort  made  when  the  resistance  is  greatest.  This  is  no 
doubt  true  if  we  look  to  duration,  but  not  if  we  attend  to  the  degree 
exhibited  in  a  given  time.  Were  there  no  resistance  offered,  the 
uterus  would  contract  at  once,  and  expel  the  foetus  by  a  single  ef- 
fort ;  and  this,  or  nearly  this,  in  a  few  cases  has  taken  place,  and 
no  great^pain  has  attended  the  process.  On  the  other  hand,  even 
a  very  slight  resistance  does  in  many  cases  diminish  the  degree  of 
contraction  or  expulsive  effort,  and  in  proportion  as  this  resistance 
is  removed,  so  does  the  contraction  increase.  Hence,  as  the  os 
uteri  relaxes  or  opens,  so  does  the  expulsive  power  augment,  and 
it  is  experience  alone  which  can  convince  us  how  small  a  resist- 
ance maybe  the  mean  of  parrying,  if  I  may  use  the  expression,  the 
contraction  of  the  fibres,  or  preventing  them  from  acting  briskly 
and  quickly.  Labour,  therefore,  is  more  certainly  shortened,  by 
promoting  relaxation,  and  diminishing  resistance,  than  by  means 


3W 

intended  to  stimulate  to  action.  At  the  same  time  it  must  not  be 
forgotten,  that  continued  resistance  does  at  last  rouse  up  the  ute- 
rine action,  and  call  forth  frequent  and  powerful  efforts,  often  ac- 
companied with  great  pain.  These  are  more  easily  excited,  when 
the  resistance  proceeds  from  the  pelvis  or  perineum,  and  orifice  of 
the  vagina,  or  the  position  of  the  child,  than  when  it  arises  from  the 
state  of  the  os  uteri,  or  even  of  the  membranes,  in  which  case  the 
uterine  action  is  long  feeble  or  inefficient.  It  is  necessary  farther 
to  remark,  that  often  a  mistake  is  committed  in  confounding  fre- 
quent and  painful  contraction  of  the  uterus,  with  powerful  and  effi- 
cient action. 

Parturition  is  a  muscular  action,  and  we  might  in  one  view  con- 
ceive that  it  should  be  most  speedy  and  easy  in  those  who  pos- 
sessed a  powerful  muscular  system,  and  great  vigour.  But  this  is 
far  from  being  the  case,  for  the  process  is  tedious  or  speedy,  easy 
or  difficult,  according  to  the  relation  which  the  power  bears  to  the 
obstacle  to  be  overcome.  Now,  in  many  weak  and  debilitated 
women,  the  parts  very  easily  relax  and  dilate,  and  a  very  small 
power  is  required  to  complete  the  expulsion;  whilst  we  often  find, 
that  those  who  possess  a  tense  fibre,  and  great  strength  of  the  mus- 
cular system,  accomplish  the  dilatation  of  the  os  uteri,  not  without 
much  pain,  and  repeated  efforts. 

A  fundamental  principle  then  in  midwifery  is,  that  relaxtion  or 
diminution  of  resistance  is  essential  to  an  easy  delivery :  and  could 
we  discover  any  agent  capable  of  effecting  this  rapidly  and  safely, 
we  should  have  no  tedious  labour,  excepting  from  the  state  of  the 
pelvis,  or  position  of  the  child.  This  agent  has  not  yet  been  dis- 
covered. Blood-letting  does  often  produce  salutary  relaxation, 
but  it  cannot  always  be  depended  on,  neither  is  it  always  safe. 

§  5.  MANAGEMENT  OF  LABOUR. 

Women  in  a  state  of  nature  make  little  preparation  for  their  de- 
livery, and  conduct  the  process  of  parturition  without  much  cere- 
mony. They  retire  to  the  woods,  or  seclude  themselves  in  a  hut 
or  bower,  Until  they  bear  the  child ;  after  which,  if  the  religious 


367 

customs  of  their  country  do  not  require  their  separation  for  a  time, 
they  return  to  their  usual  mode  of  living. 

In  Europe,  [and  in  a  state  of  civilization  generally,]  we  find  that 
the  process  of  parturition  is  conducted  with  more  care,  and  is  sup- 
posed to  require  greater  preparation.  Different  countries  have  dif- 
ferent customs  in  this  respect.  In  some,  women  are  delivered  upon 
a  chair  of  a  particular  construction  ;  in  others,  seated  on  the  lap 
of  a  female  friend.     Some  women  use  a  little  bed,  on  which  they 
rest,  until  the  process  is  completed ;  and  others  are  delivered  on 
the  bed  on  which  they  usually  sleep.     This  last,  for  many  reasons, 
is  the  best  and  most  proper  practice ;  but  in  order  to  prevent  the 
bed  from  being  spoiled,  or  wet  with  the  liquor  amnii  or  blood,  and 
also  from  other  motives  of  comfort,  it  is  usual  to  make  it  up  in  a 
particular  manner.     The  mattress  ought  to  be  placed  uppermost, 
and  a  dressed  skin,  or  folded  blanket  placed  on  that  part  of  it  on 
which  the  breech  of  the  woman  is  to  rest.     The  bed  is  then  to  be 
made  up  as  usual ;  after  which,  a  sheet  folded  into  a  breadth  of 
about  three  feet,  is  put  across  the  under  fold  of  the  bed-sheet.  This 
is  intended  to  absorb  the  moisture;  and  after  delivery,  if  not  dur- 
ing labour,  that  part  which  is  wet,  is  to  be  drawn  completely  away, 
so  that  a  dry  portion  may  be  brought  under  the  woman.     This  ar- 
rangement is  generally  attended  to  by  the  nurse,  whenever  labour 
begins.     When  the  pains  begin,  the  woman  generally  dresses  in 
dishabille ;  but  when  the  process  is  considerably  advanced,  it  is 
necessary  to  undress,  and  lie  in  bed.     Some,  at  this  time,  put  on 
a  half  shift,  that  is  to  say,  one  that  does  not  reach  below  the  waist, 
so  that  it  is  not  liable  to  be  wet.     Others  are  satisfied  with  having 
the  shift  pushed  up  over  the  pelvis,  so  as  to  be  kept  dry  ;  its  place, 
in  either  case,  is  supplied  with  a  petticoat.     These,  and  other  cir- 
cumstances relating  to  dress,  and  to  the  quantity  of  bed-clothes, 
must  be  determined  by  the  woman  herself,  and  the  season  of  the 
year. 

It  is  of  consequence  that  the  room  be  not  over-heated  by  fire,  or 
the  patient  kept  too  warm  with  clothes.  Heat  makes  her  restless 
and  feverish,  adds  to  the  feeling  of  fatigue,  and  often,  by  rendering 
the  pains  irregular  or  ineffective,  protracts  the  labour.  No  more 
people  should  be  in  the  room  than  are  absolutely  necessary.     The 


36'6  * 

nurse  and  one  female  friend  are  perfectly  sufficient  for  every  good 
purpose  ;  and  a  greater  number,  by  their  conversation,  disturb  the 
patient,  or  by  their  imprudence,  may  diminish  her  confidence  in 
her  own  powers,  and  also  in  her  necessary  attendants.  The  mind* 
in  a  state  of  distress,  is  easily  alarmed  ;  and  therefore  whispering, 
and  all  appearance  of  concealment,  ought  to  be  prohibited  in  the 
room. 

If  the  woman  be  disposed  to  sleep  betwixt  the  pains,  she  ought 
not  to  be  disturbed,  but  allowed  to  indulge  in  repose.  If  she  have 
not  this  inclination,  and  be  not  fatigued,  cheerful  conversation, 
upon  subjects  totally  unconnected  with  her  situation,  will  be  very 
proper. 

Women  have  seldom  an  inclination  for  food  whilst  tbey  are  in 
labour  ;  and,  if  the  process  be  not  long  protracted,  there  is  no  oc- 
casion for  it.  If,  however,  the  patient  have  a  desire  to  eat,  she 
may  have  a  little  tea  or  coffee,  with  dry  toast,  or  a  little  soup,  or 
some  panado  ;  but  every  thing  which  is  heavy  or  difficult  of  diges- 
tion, must  be  avoided,  lest  she  be  made  sick  and  restless,  or  have 
her  recovery  afterwards  interrupted.  Even  very  light  food  is  apt 
at  this  time  to  sour,  and  cause  heartburn. 

Stimulants  and  cordials,  such  as  spiced  gruel,  cinnamon  water, 
wines,  and  possets,  were  at  one  time  very  much  employed,  but 
now  are  deservedly  abandoned  by  those  who  follow  the  dictates  of 
nature.  Given  in  liberal  doses,  they  are  productive  of  great  dan- 
ger, disposing  to  fever  or  inflammation  after  delivery;  and  in 
smaller  doses,  they  disorder  the  stomach,  and  often,  instead  of  for- 
warding, retard  the  labour.  If,  however,  the  woman  be  weak,  or 
the  process  tedious,  then  a  small  quantity  of  wine,  given  prudently, 
may  be  of  considerable  advantage. 

Some  women  wish  to  keep  out  of  bed  as  much  as  possible,  in 
order  that  labour  may  be  forwarded  by  walking  about ;  others  have 
the  same  desire,  from  feeling  easier  when  they  are  sitting.  In  this 
respect  they  may  be  allowed  to  please  themselves,  but  they  ought 
to  be  as  much  as  possible  out  of  bed,  provided  they  do  not  feet 
tired. 

The  urine  ought  to  be  regularly  and  frequently  evacuated  ;  and 
for  that  purpose,  the  practitioner  should  occasionally  leave  the 


/ 


369 

room.  If  the  woman  be  costive,  or  the  rectum  contain  faeces,  a 
clyster  ought  always  to  be  given  early,  which  facilitates  the  labour. 
On  the  other  hand,  if  the  bowels  be  very  loose,  a  few  drops  of 
tincture  of  opium  may  be  given  with  much  advantage. 
,/'  It  is  immaterial  in  what  posture  the  patient  place  herself  during 
the  first  stage  of  labour  ;  but  in  the  second  stage,  when  delivery  is 
approaching,  it  is  proper  that  she  be  placed  on  her  side,  and  it  is 
usual  for  her  to  lie  on  the  left  side,  as  this  enables  the  practitioner 
to  use  his  right  hand.  The  knees  are  a  little  drawn  up,  and  gen- 
erally at  this  time  kept  separate  by  means  of  a  small  pillow  placed 
between  them.  Many  women  wish  to  have  their  feet  supported, 
or  pressed  against  by  an  assistant,  and  it  is  customary  to  give  a 
towel  to  grasp  in  the  hand.  This  is  either  held  by  the  nurse,  or 
fastened  to  the  bed  post.  We  must,  however,  be  careful  that  these 
contrivances  do  not  encourage  the  woman  to  make  too  strong  ef- 
forts to  bear  down. 

When  the  woman  is  in  bed,  it  is  proper  to  have  a  soft  warm 
cloth  applied  to  the  external  parts,  in  order  to  absorb  any  mucus 
or  water  that  may  be  discharged,  and  this  is  to  be  removed  when 
it  is  wet. 

Attempts  to  dilate  the  os  uteri  or  the  vagina,  and  the  application 
of  unctuous  substances,  to  lubricate  the  parts,  are  now  very  pro- 
perly abandoned  by  well  instructed  practitioners. 

The  membranes  ought  generally  to  be  allowed  to  burst,  by  the 
efforts  of  the  uterus  alone,  for  this  is  the  regular  course  of  nature  ; 
and  a  premature  evacuation  of  the  water  either  disorders  the  pro- 
cess and  retards  the  labour,  or,  if  it  accelerate  the  labour,  it  ren- 
ders it  more  painful.  I  cannot,  however,  go  the  length  of  some,  who 
say,  that  the  evacuation  of  the  water  is  always  hurtful ;  for  there 
are  circumstances  in  which  it  may  be  allowable  and  beneficial. 
It  is  allowable  when  the  os  uteri  is  fully  dilated,  and  the  membranes 
protruded,  perhaps  even  out  of  the  vagina.  In  such  a  case,  they 
would,  in  a  few  pains,  at  farthest,  give  way  ;  but  by  rupturing  them 
we  can  take  precautions  to  keep  the  person  dry,  and  more  com- 
fortable than  she  would  otherwise  have  been.  Even  if  the  mem- 
branes are  not  considerably  protruded,  if  the  os  uteri  be  completely 
dilated  no  injury  can  arise  from  rupturing  them,  for  they  ought,  in 

48 


\ 


370 

the  natural  course  of  labour,  to  give  way  at  this  time.  But  although 
the  practice  be  not  detrimental,  yet  it  does  not  thence  follow  that 
it  is  always  expedient ;  and  it  will  be  a  useful  rule  to  adhere  to, 
that  the  seldomer  we  interfere  in  tliis  respect  in  a  natural  labour, 
the  more  prudent  shall  our  conduct  be. 

Examination  ought,  in  the  first  stage  of  labour,  to  be  practised 
seldom  ;  but  in  the  second  stage  we  must  have  recourse  to  it  more 
frequently  ;  and,  when  the  pains  are  becomiug  stronger  and  the 
head  advancing,  we  must  not  leave  the  bedside.  At  this  time  we 
should  be  prepared  for  the  reception  of  the  child.  A  pair  of  scis- 
sors, with  some  short  pieces  of  narrow  tape,  must  be  laid  upon  the 
bed  or  chair,  and  a  warm  cloth  or  receiver  must  be  at  hand,  or 
spread  under  the  clothes,  to  wrap  the  child  in.  As  the  faeces  are 
generally  passed  at  this  time  involuntarily,  a  soft  cloth  is  to  be  laid 
on  the  perineum  ;  and  when  the  second  stage  of  labour  is  drawing 
to  a  conclusion,  the  hand  is  to  be  placed  on  this,  in  order  to  pre- 
vent the  rapid  delivery  of  the  head,  and  the  consequent  laceration 
of  the  perineum.  This  is  a  point  of  very  great  importance,  and 
which  requires  to  be  carefully  considered  by  the  practitioner. 
There  are  several  arguments  against  this  practice  ;  for  we  should, 
a  priori,  conceive,  that  as  parturition  is  a  natural  process,  it  ought 
•  not  in  any  part  to  be  defective,  or  to  require  the  regulation  of  art. 
Next,  we  should  strengthen  this  doctrine,  by  finding,  that  in  the 
savage  state,  a  lacerated  perineum  is  rarely  discovered,  and  in  all 
those  women  who  are  speedily  delivered  by  themselves,  the  recto- 
vaginal septum  is  seldom  torn.  But  on  the  other  hand,  the  fact 
is  ascertained  beyond  all  dispute,  that  the  perineum  is  sometimes 
lacerated,  notwithstanding  these  presumptive  proofs  against  the 
occurrence  of  the  accident.  This  being  ascertained,  it  becomes 
our  duty,  however  rare  the  case  may  be,  to  determine  its  causes, 
and  prevent  its  occurrence  in  every  instance  ;  for  we  cannot  exact- 
ly say  who  the  unfortunate  individuals  may  be,  to  whom  it  is  to 
happen.  We  may  decidedly  say,  that  the  perineum  is  torn  in  con- 
sequence of  distention  ;  but  in  every  delivery,  the  perineum  must 
be  distended,  and  in  some  to  a  great  degree.  In  proportion  to  the 
facility  of  the  distention,  and  the  ease  with  which  the  vagina  dilates, 
is  the  risk  of  laceration  diminished.     It  has,  therefore,  become  a 


371 

practical  rule,  to  resist,  with  the  hand  placed  on  the  perineum; 
the  delivery  of  the  head,  until  the  parts  he  sufficiently  relaxed  ; 
and  this  pressure  ought  to  be  exerted  over  the  whole  tumour,  but 
especially  at  the  fourchette ;  for  although  the  perineum  has  been 
perforated  by  the  head,  which  did  not  pass  through  the  orifice  of 
the  vagina,  yet  usually,  the  rent  begins  at  the  fourchette  and  pro- 
ceeds backwards  to  a  greater  or  less  degree.  In  every  case,  the 
fourchette,  and  a  small  part  of  the  posterior  surface  of  the  vagina, 
are  lacerated,  though  the  integuments  of  the  perineum  remain 
sound.  By  firmly  supporting  the  perineum,  and  at  the  same  time, 
exhorting  the  woman  not  to  force  down  during  a  pain,  and  thus 
retarding  the  delivery  of  the  head  until  we  feel  the  vulva,  as  well  as 
the  perineum  relaxing,  we  may  generally  prevent  laceration  ;  and 
therefore  this  accident  will  seldom  if  ever  happen  in  the  hands  of 
a  prudent  practitioner.  Still  it  is  possible  for  the  perineum  to  be 
torn  under  good  management.  A  little  bit  of  it  is  not  unfrequently 
lacerated,  notwithstanding  all  our  precaution  ;  and  although,  in  this 
slight  degree,  it  is  of  no  consequence,  yet  we  thus  see  that  art 
cannot  completely  prevent  the  accident.  Sometimes  the  restless- 
ness of  the  patient  almost  inevitably  prevents  the  necessary  pre- 
cautions from  being  used  ;*  and  it  may  happen,  that  the  frame  is  so 
very  irritable,  that  the  perineum  unexpectedly  lacerates  at  the  time 
when  it  is  supposed  to  be  in  a  favourable  state.  As  there  must  be 
some  point  where  the  resistance  must  stop,  else  the  labour  would 
be  unnecessarily  protracted,  or  perhaps  even  the  uterus  ruptured, 
it  is  possible  that  such  resistance  may  be  made,  as  generally  is.- 
sufficient  to  prevent  the  accident,  but  which  may  not  in  some  par- 
ticular case,  owing  to  the  irritable  state  of  the  perineum,  be  ade- 
quate to  the  intended  purpose ;  or  the  power  of  the  uterus  may  be 
so  strong  as  to  expel  the  head,  in  spite  of  every  allowable  resis- 
tance ;  and  in  some  of  these  cases  it  is  possible  for  the  perineum 
to  be  torn. 

It  is  not  sufficient  that  the  practitioner  support  the  perineum, 
until  the  head  is  going  to  be  expelled ;  he  must  continue  to  do  so 

\  *  Dr.  Denman,  a  most  worthy  and  experienced  practitioner,  with  a  candour 
which  does  him  honour,  akcnowledges,  that  from  this  cause  the  accident  occur- 
red in  his  own  practice. 


whilst  it  is  passing  out,  for  there  is  then  a  great  strain  on  the 
part,  as  the  forehead  is  passing  over  the  perineum,  and  even 
the  face  moving  along  it,  may  produce  injury.  After  the  head  is 
delivered,  it  is  still  necessary  to  place  the  hand  under  the  chin, 
and  on  the  perineum,  for  the  arm  of  the  child  comes  next  to  press 
against  this  part,  and  may  either  tear  it  by  pressure,  or  by  coming 
out  with  a  jerk.    Farther,  to  prevent  injury  and  avoid  pain,  the  body 

\of  the  child  should  be  allowed  to  pass  out  in  a  direction  correspond- 
ing to  the  outlet  of  the  pelvis,  that  is  to  say,  moving  a  little  for- 
wards. But  there  is  no  occasion  that  the  child  should  be  carried 
1  for  ward  betwixt  the  thighs,  for,  in  a  natural  labour,  the  back  of  the 
child  is  directed  to  the  thighs  ;  he  can  easily  bend  and  will  natu- 
rally so  incline  himself  in  the  delivery,  as  to  take  the  proper  direc- 
tion. The  last  advice  to  be  given  respecting  this  stage  of  labour 
is,  that  as  we  retard  rather  than  encourage  the  expulsion  of  the 
head,  so  we  are  not  to  accelerate  the  delivery  of  the  body.  Women  ■ 
in  a  state  of  pain  call  for  relief,  and  expect  that  the  midwife  is  to  \ 
assist  the  delivery  of  the  child  ;  but  no  entreaties  ought  to  make  us  J 
lhasten  the  expulsion  of  the  head,  and  after  that  event,  there  is 
little  inducement  to  accelerate  the  labour.  Sometimes,  in  a  few- 
seconds,  the  child  is  expelled,  but  there  may  be  a  cessation  of  pain 
for  some  minutes.  In  the  first  case,  we  take  care  that  the  body  be 
not  propelled  rapidly,  and  with  a  jerk  :  in  the  second,  we  attend  to 
the  head,  examining  that  the  membranes  do  not  cover  the  mouth, 
but  that  the  child  be  enabled  to  breathe,  should  the  circulation  in 
the  cord  be  obstructed.  There  is  no  danger  in  delay,  and  rashly 
pulling  away  the  child,  is  apt  to  produce  flooding  and  other  dan- 
gerous accidents.  Should  there,  however,  be  a  considerable  inter- 
val betwixt  the  expulsion  of  the  head,  and  the  accession  of  new 
pains,  we  may  press  gently  on  the  belly,  or  pull  the  child  slightly, 
so  as  to  excite  the  uterus  to  contract.  Or,  should  the  woman  have 
several  pains  without  expelling  the  body  of  the  child,  it  may  be  al- 
lowable gently  to  insinuate  the  finger,  and  bring  down  the  shoul- 
der ;  but  even  this  assistance  is  rarely  required,  and  on  no  account 
Ought  we  to  attempt  the  delivery  by  pulling  the  head.  Sometimes 
a  delay  is  produced  by  the  cord  being  twisted  round  the  neck ; 
and  in  this  case,  all  we  have  to  do,  is  to  slip  it  off  over  the  head. 


373 

The  child  being  born,  a  ligature  is  to  be  applied  on  the  cord 
very  near  the  navel,  and  another  about  two  inches  nearer  the  pla- 
centa.(c)  It  is  then  to  be  divided  betwixt  them,  and  the  child  re- 
moved. The  hand  is  next  to  be  placed  on  the  belly,  to  ascertain 
that  there  be  not  a  second  child  ;(d)  and  the  finger  may,  for  the 
same  purpose,  be  slid  gently  along  the  cord  to  the  os  uteri.  The 
hand  of  an  assistant  should  be  applied  on  the  abdomen,  and  gently 
pressed  on  the  uterus,  which  may  excite  it  to  action,  and  prevent 
torpor.  If  the  placenta  be  not  expelled  soon,  the  uterine  region 
may  be  rubbed  with  the  hand  to  excite  the  contraction  of  the 
womb.  Immediately  after  the  expulsion  of  the  child,  there  is  of- 
ten a  copious  evacuation  of  water,  which  is  sometimes  mistaken 
by  the  woman  for  a  discharge  of  blood.  But  hemorrhage  never 
takes  place  so  instantaneously,  in  such  quantity.  It  is  generally  a 
minute  or  two,  sometimes  much  longer,  before  flooding  come 
on  ;  against  the  occurrence  of  this,  we  are  to  be  on  our  guard. 

fcj  The  ligature  should  not  be  applied,  until  the  pulsation  of  the  funis  has 
ceased,  or  at  least  until  the  child  has  cried,  that  the  new  circulation  now  to  com- 
mence may  be  thus  properly  established.  Until  this  has  taken  place,  the  life  of 
the  child,  according  to  Mr.  White,  is  to  be  considered  as  merely  foetal,  or  as  if  it 
were  yet  in  utero.  Whilst  there  remains  a  pulsation  of  the  arteries  of  the  funis, 
it  proves  the  existence  of  the  foetal  life,  and  the  existence  of  the  fatal  life  proves 
the  imperfection  of  the  animal  life.  Whilst  the  animal  life,  therefore,  is  imper- 
fect, Mr.  White  lays  it  down  as  a  ride,  that  the  foetal  life  ought  not  to  be  destroy- 
ed. The  funis  umbilicalis,  therefore,  should  never  be  divided  or  tied,  whilst 
there  is  any  pulsation  in  its  arteries.  "  By  this  rash  inconsiderate  method  of  ty- 
ing the  navel  string,  before  the  circulation  in  it  is  stopt,  I  doubt  not  (continues 
Mr.  White)  but  many  children  have  been  lost,  many  of  their  principal  organs 
have  been  injured,  and  foundations  laid  for  various  disorders."  White  on  the 
Management  of  Pregnant  and  I.ying-in  Women,  page  87. 

Whilst  on  the  subject  of  tying  the  funis,  we  may  mention  an  observation  of  Sa- 
batier,  which  i3  worthy  of  notice.  He  says  that  he  has  often  known,  in  cases  of 
congenital  umbilical  hernia,  that  the  displaced  intestines  have  protruded  along 
the  umbilical  cord  without  much  increasing  its  size,  and  have  been  tied  by  the 
ligature  made  on  it,  occasioning  the  death  of  the  infant.  Medicine  Operatoire, 
Tom.  I.  p.  152. 

fdj  If  a  second  child  remain,  we  very  distinctly  feel  the  enlarged  uterus  be- 
tween the  pubis  and  umbilicus,  and  even  above  the  latter,  and  not  so  much  di- 
minished in  size  as  we  should  have  previously  supposed,  but  if  there  is  no  second 
child,  we  feel  the  uterus  contracted  into  a,  small  round  ball,  extending  not  far 
above  the  symphysis  pubis. 


'■ 


374 

The  Woman,  after  the  delivery  of  the  child,  feels  quite  well,  and 
expresses,  in  the  strongest  language,  the  transition  from  suffering 
to  tranquility.  But  in  a  short  time,  generally  within  half  an  hour, 
one  or  two  trifling  pains  are  felt,  and  the  placenta  is  expelled, 
which  completes  the  last  stage  of  parturition  ;  and  when  the  pro- 
cess goes  on  regularly,  nothing  is  required  in  this  stage,  except 
watchfulness,  lest  hemorrhage  supervene. 

But  it  sometimes  happens,  that  the  placenta  does  not  come  away 
so  early  or  so  readily  as  we  expect.  It  may  be  retained  for  many 
hours,  or  even  for  some  days.  This  retention  can  be  caused  by 
preternatural  adhesion  of  the  placenta,  or  by  the  uterus  contracting 
spasmodically  round  the  placenta,  forming  a  kind  of  cyst,  in  which 
it  is  contained  j  or  the  uterus  may  not  contract  on  the  placenta  so 
strongly  as  to  expel  it.  Some,  from  a  confidence  in  the  powers  of 
nature,  have  inculcated  as  a  rule  of  conduct,  that  unless  flooding 
take  place,  the  placenta  ought  not  to  be  extracted.  Others  have, 
with  equal  zeal,  advised  it  to  be  brought  away  immediately  after 
the  birth  of  the  child.  The  safest  practice  seems  to  lie  betwixt  the 
two  extremes.  To  leave  the  expulsion  of  the  placenta  altogether 
to  nature,  is  a  step  attended  with  great  danger ;  for  so  long  as  it  is 
retained,  we  may  be  sure  that  the  uterus  has  not  contracted  strong- 
ly and  regularly.  If  then,  in  these  circumstances,  the  placenta 
should  be  partially  or  completely  detached,  hemorrhage  is  very 
likely  to  occur.  If  it  still  adhere  to  the  uterus,  the  risk  of  hemorr- 
hage certainly  is  diminished,  for  those  vessels  alone,  which  open- 
ed on  the  decidua,  can  be  exposed ;  but  we  have  no  security  that 
this  adhesion  shall  remain  universal  for  any  given  time.  As  long; 
then,  as  the  placenta  is  retained,  the  woman  is  never  free  from  the 
risk  of  flooding.  In  many  cases,  she  has  died  from  this  cause  be- 
fore the  placenta  was  expelled ;  or  if,  after  a  long  delay,  the  pla- 
centa has  come  away,  its  exclusion  has  sometimes  been  followed 
by  fatal  hemorrhage.*  But  this,  although  a  dreadful  accident,  is 
not  the  only  one  arising  from  retention  of  the  whole  or  part  of  the 

*  Mr.  White  has,  in  his  Treatise  on  the  Management  of  Pregnant  and  Lying- 
in  Women,  p.  507,  related  several  cases  where  the  practice  of  leaving  the  pla- 
centa to  be  expelled  by  nature  alone,  was  productive  of  fatal  hemorrhage  ;  and 
in  one  instance,  this  event  took  place,  although  the  placenta  was  at  last  expelled. 


375 

placenta.  For  great  debility,  constant  retching,  and  fever,  are  of- 
ten produced  by  this  cause,  and  may  ultimately  carry  off  the  pa- 
tient.fej  It  is  therefore  not  without  great  reason,  that  women  are 
anxious  for  the  expulsion  of  the  placenta ;  and  this  prejudice  may 
have  a  good  effect  in  operating  against  the  conceits  of  speculative 
men,  who  suppose  that  nature  is,  in  every  instance,  adequate  to  the 
accomplishment  of  her  own  purposes. 

On  the  other  hand,  daily  experience  must  convince  every  one, 
that  there  is  no  occasion  for  extracting  the  placenta  immediately 
after  the  birth  of  the  child,  for  it  is  usually  expelled,  with  perfect 
safety,  within  forty  minutes  after  the  child  is  delivered.  Nay,  we 
find,  that  the  speedy  extraction  of  the  placenta  is  directly  hurtful ; 
both  as  it  is  painful,  and  also  as  it  is  sometimes  followed  by  uterine 
hemorrhage,  or,  if  rashly  performed,  by  inversion  of  the  womb. 
The  practice  then,  I  think,  may  be  comprised  in  two  directions  : — 
First,  that  we  ought  never  to  leave  the  bed-room,  until  the  pla- 
centa be  expelled  ;  and,  secondly,  that  if  it  be  not  excluded  in  an 
hour  after  delivery,  we  ought  to  extract  it.  This  point  being  ad- 
justed, it  is  next  to  be  inquired,  how  the  retention  is  to  be  pre- 
vented, and,  if  not  prevented,  how  the  placenta  is  to  be  extracted. 
With  regard  to  the  first  question,  it  may  be  answered,  that  the 
placenta  will  be  less  apt  to  be  retained,  if  the  expulsion  of  the 
child  be  conducted  slowly,  and  the  uterus  made  to  contract  fully 
upon  it.  The  action,  if  not  likely  soon  to  take  place,  may  be 
sometimes  excited  by  pressing  on  the  uterine  region,  and  rubbing 
the  abdominal  covering  over  the  uterus,  or  gently  grasping  the 
womb  through  the  relaxed  parietes.  As  to  the  mode  of  extracting 
the  placenta,  we  can  be  at  no  loss,  if  we  recollect  that  the  expul- 


fej  The  celebrated  Ruysch,  we  are  told,  was  the  first  to  abandon  the  absurd 
practice  of  hasty  extraction  of  the  placenta,  enlightened,  no  doubt,  by  his  supe- 
rior anatomical  knowledge.  Dr.  Hunter  in  Great  Britain,  fuily  pointed  out  its 
impropriety.    He  however  erred  on  the  other  extreme  ; 

"  Incidit  in  Scyllam  cupiens  vitare  Charybdim." 

Teaching  that  nature  unassisted  was  adequate  to  the  expulsion  of  the  placenta 
in  every  case,  he  never  interfered ;  but  experience,  says  Dr.  Hamilton,  soon 
taught  him  the  error  of  this  practice  ;  for  by  suffering  the  placenta  to  remain  too 
long,  he  lost  five  patients  of  rank  in  one  year. 


/ 


376 

sion  is  accomplished  by  the  contraction  of  the  uterus.  Our  object, 
then,  is  to  excite  this  when  the  placenta  is  retained,  in  consequence 
of  the  womb  not  acting  strongly.  The  hand  is  to  be  slid  slowly 
and  cautiously  into  the  uterus,  which  is  often  sufficient  to  make  it 
contract ;  but  if  it  do  not,  the  hand  is  to  be  moved  a  little,  or 
pressed  gently  on  the  placenta,  at  the  same  time  that  we  pull  very 
slightly  by  the  cord,  or  lay  hold  of  the  detached  placenta  with  our 
hand,  and  with  caution  extract  it  slowly.  This  requires  no  exer- 
tion, for  the  uterus  is  pressing  it  down,  and,  if  any  force  be  used, 
we  do  harm.  Attempts  to  bring  away  the  placenta,  by  pulling 
strongly  at  the  cord,  whether  the  hand  be  introduced  into  the 
uterus  or  not,  are  always  improper.  If  persisted  in,  they  gene- 
rally end,  either  in  the  laceration  of  the  cord,  or  the  inversion  of 
the  uterus. 

There  are  two  circumstances,  however,  under  which  the  pla- 
centa may  be  retained,  which  require  some  modification  of  the 
practice.  The  first  is,  when  the  placenta  is  retained  by  spasm. 
In  this  case,  when  the  hand  is  conducted  along  the  cord  through 
the  os  uteri,  the  placenta  is  not  perceived,  but  it  is  led  by  the 
cord  to  a  stricture,  like  a  second,  but  contracted  os  uteri,  beyond 
which  the  placenta  is  lodged.  This  contraction  must  be  overcome 
before  the  placenta  can  be  brought  away,  which  may  be  accom- 
plished by  gradual  attempts  to  introduce  one,  two,  and  ultimately 
all  the  fingers  through  it;  and  these,  if  cautiously  made,  are  per- 
fectly safe.  It  will,  however,  be  observed,  that  the  uterus,  at  short 
intervals,  contracts,  which  is  accompanied  with  pain ;  but  this 
contraction  is  confined  to  the  stricture  alone,  the  cavity  of  the 
womb  not  being  lessened  by  it ;  and  during  this  state,  all  attempts 
to  dilate  the  aperture  are  hurtful.  We  must  be  satisfied  with 
keeping  the  fingers  in  their  place,  to  preserve  the  ground  we  have 
gained.  Opiates  have  been  proposed  to  remove  this  spasm,  and 
render  the  introduction  of  the  hand  unnecessary ;  they  seldom, 
however,  succeed  alone,  but  given  in  a  full  dose  they  make  the 
manual  attempt  more  easy.  Sometimes  the  sudden  application 
of  a  cloth,  dipped  in  cold  water,  to  the  belly,  has  the  same  effect. 
The  second  circumstance  to  which  I  alluded  is,  adhesion  of  the 
placenta,  which  usually  is  only  partial.     This  may  occur  with  or 


'■without  a  change  of  structure;  but  in  general,  the  structure  is 
more  or  less  altered,  the  adhering  part  being  denser  than  usual, 
and  sometimes  almost  like  cartilage.  The  separation  of  the  ad- 
hering portion  should  not  be  attempted  hastily,  nor  by  insinuating 
the  finger  between  it  and  the  uterine  surface.  It  is  better  to  press 
on  the  surface  of  the  placenta,  so  as  thus  to  excite  the  uterine 
fibres  to  contract  more  briskly  at  the  spot ;  or  by  gently  rubbing, 
or  as  it  were,  pinching  up  the  placenta  between  the  fingers  and 
thumb,  it  may  be  separated.  If,  however,  the  adhesion  of  the 
part  of  the  placenta  be  very  intimate,  we  must  not,  in  order  to 
destroy  it,  scrape  and  irritate  the  surface  of  the  uterus,  but  ought 
rather  to  remove  all  that  does  not  adhere  intimately,  leaving  the 
rest  to  be  separated  by  nature.*  But  in  taking  this  step,  we  aro 
not  to  proceed  with  impatience,  nor  to  attempt  to  bring  away  the 
non-adhering  portion,  until  a  considerable  time  has  elapsed,  and 
cautious  efforts  have  been  made  to  remove  the  entire  placenta ; 
thus  satisfying  ourselves  of  the  existence  of  an  obstinate  and  inti- 
mate union.  Cases  where  this  conduct  is  necessary,  are  very  rare* 
and  when  they  do  occur,  there  is  usually  an  induration  of  the  ad- 
hering part.  It  is  generally  thrown  off  in  a  putrid  state  in  forty- 
eight  hours.  Sometimes  the  placenta  adheres  when  it  is  unusually 
tender  and  soft,  and  then  we  must,  with  peculiar  care,  avoid  hasty 
efforts,  by  which  the  placenta  would  be  lacerated,  and  part  left 
behind,  which  would  be  hurtful  afterwards ;  whereas  by  a  little 
more  patience,  and  gentle  pressure  on  the  surface  of  the  placenta, 
the  uterus  might  have  been  excited  to  throw  the  whole  off. 

*  Dr.  Smellie  relates  two  cases  of  this  kind.  In  the  first,  he  brought  away  the 
indurated  portion,  but  the  woman  died  from  hemorrhage.  In  the  second,  he 
left  the  adhering  portion,  and  the  woman  recovered.  Col.  23.  c.  1  and  2.  See 
also  GifFord's  Cases,  c.  119  and  127  :  and  La  Motte,  c.  358  and  362.  In  these, 
although  the  adhesion  was  very  intimate,  he  brought  away  tja.e  placenta  in 
^pieces. 


40 


378 

chap.  in. 

Of  Premature  Labour. 

When  a  woman  bears  a  child  in  the  seventh  or  eighth  month 
of  pregnancy,  she  is  said  to  have  a  premature  labour ;  and  this 
process  forms  a  medium  between  abortion  and  natural  labour. 

In  some  cases,  the  uterus  is  fully  developed  before  the  usual 
term  of  gestation,  and  then  contraction  commences  ;  but,  in  a  great 
majority  of  instances,  premature  labour  proceeds  from  accidental 
causes,  exciting  the  expulsive  action  of  the  uterus,  before  the  cer- 
vix and  os  uteri  have  gone  through  their  regular  changes.  The 
cervix  must,  therefore,  be  expanded  by  muscular  action,  before 
the  os  uteri  can  be  properly  dilated  ;  and  this  preparatory  stage  is 
generally  marked  by  irregular  pains,  and  not  unfrequently  by  a 
feverish  state,  preceded  by  shivering.  A  feeling  of  slackness  about 
the  belly,  with  different  anomalous  sensations,  often  accompany 
this  stage  of  premature  labour.  When  the  cervix  is  expanded, 
then  the  os  uteri  begins  to  dilate,  and  this  part  of  the  process  is 
often  more  tedious  than  the  same  period  of  natural  labour,  and 
generally  as  painful.  It  is  also  frequently  attended  with  a  bearing- 
down  sensation.  The  second  stage  of  labour  is  usually  expedi- 
tious, owing  to  the  small  size  of  the  child.  The  decidua  being 
thicker  than  at  the  full  time,  the  protrusion  of  the  membranes  is 
attended  with  more  sanguineous  discharge  ;  and  if  the  woman 
move  much,  or  exert  herself,  considerable  hemorrhage  may  take 
place.  The  third  stage  is  likewise  slow,  for  the  placenta  is  not 
soon  thrown  off.  In  the  last  place,  spasmodic  contraction  of  the 
uterus  is  more  apt  to  take  place  in  all  the  stages  of  premature  than 
of  natural  labour. 

A  variety  of  causes  may  excite  the  action  of  the  uterus  prema- 
turely, such  as  distention  from  too  much  water  j  or  the  death  of  the 
child,  which  is  indicated  by  shivering,  subsidence  of  the  breasts, 
cessation  of  motion,  and  of  the  symptoms  of  pregnancy  ;  or  the  ar- 
tificial evacuation  of  the  liquor  amnii ;  or  violent  muscular  exer- 
tion ;  or  drugs  acting  strongly  on  the  stomach  and  bowels  j  or  pas- 


379 

sions  of  the  mind ;  or  acute  diseases ;  or  rigidity  of  the  uterine 
fibres.  Certain  general  conditions  of  the  system  render  the  opera- 
tion of  these  causes  more  easy,  such  as  plethora,  debility,  and  great 
irritability.  Colic  in  some  instances,  and  diarrhcEa  in  others,  seem=> 
to  be  a  cause,  and  in  such  cases  anodyne  clysters  are  useful.  Pre- 
mature labour  is  often  preceded  by  severe  shivering,  during  or  im- 
mediately before  which  the  child  dies,  and  in  some  time  thereafter, 
pains  come  on.  It  is  worthy  of  notice  that  a  much  larger  propor- 
tion of  premature  labours  are  preternatural,  than  of  labours  at  the 
full  time. 

A  tendency  to  premature  labour  is  to  be  prevented  by  the  means 
pointed  out  when  treating  of  abortion.  I  have  only  to  add,  that 
when  the  abdomen  is  tense  and  hard,  or  painful,  indicating  a  rigi- 
dity of  the  uterine  fibres,  or  of  the  abdominal  muscles,  tepid  fo- 
mentations, gentle  laxatives,  and  repeated  small  bleedings,  are 
useful. 

When  a  woman  is  threatened  with  premature  labour,  we  ought, 
unless  there  be  very  decided  marks  of  the  death  of  the  child,  to  en- 
deavour to  check  the  process,  which  is  done  by  exhibiting  an 
opiate,  keeping  the  patient  cool  and  tranquil,  and  removing  any 
irritation  which  may  exist.  If  she  be  plethoric  or  the  pulse  be 
throbbing,  blood  is  to  be  detracted. 

When  labour  is  established,  it  is  to  be  conducted  much  in  the 
same  way  with  parturition  at  the  full  time ;  but  the  following  ob- 
servations will  not  be  improper.  The  patient  must  avoid  much 
motion,  lest  hemorrhage  be  excited.  Frequent  examination  and 
every  irritation  are  hurtful,  by  retarding  the  process,  and  tending 
to  produce  spasmodic  contraction.  If  this  contraction  take  place, 
marked  by  paroxysms  of  pain  referred  to  the  belly  or  pubis,  little 
or  no  effect  being  produced  on  the  os  uteri,  a  full  dose  of  tincture 
of  opium  should  be  given,  after  the  administration  of  a  clyster. 
Severe  pains,  with  premature  efforts  to  bear  down,  and  a  rigid 
state  of  the  os  uteri,  require  venesection,  and  afterwards  an  opiate. 
The  delivery  of  the  child  is  to  be  retarded;  rather  than  accelerated 
in  the  last  stage,  that  the  uterus  may  contract  on  the  placenta. 
This  is  farther  assisted,  by  rubbing  gently  the  uterine  region  after 
delivery.     If  the  placenta  be  long  retained,  or  hemorrhage  come 


380 

•on,  the  hand  is  to  be  gently  introduced  into  the  uterus,  and  pressed 
on  the  placenta,  to  excite  the  fibres  to  throw  it  off;  or  we  may 
stimulate  the  uterus  to  act,  by  rubbing  externally.  We  should  not 
rashly  attempt  to  remove  it,  for  we  are  apt  to  tear  it;  neither  are 
we  to  pull  the  cord,  for  it  is  easily  broken.  In  those  cases  where 
premature  labour  is  connected  with  redundance  of  liquor  amnii,  I 
think  it  useful  to  introduce  the  hand  immediately  on  the  delivery 
of  the  child,  for  I  have  observed,  that  the  placenta  is  apt  to  be  re- 
tained by  irregular  contraction.  We  do  not  instantly  extract  the 
placenta,  but  it  is  desirable  to  get  the  hand  in  contact  with  it  be- 
fore the  circular  'fibres  contract.  Great  attention  is  to  be  paid  to 
the  patient  for  some  days  after  delivery,  as  she  is  liable  to  a  febrile 
affection,  which  may  be  either  of  the  inflammatory  type,  or  of  the 
nature  of  weed,  to  be  afterwards  noticed. 


CHAP.  IV. 

Of  Preternatural  Labour. 

Various  signs  have  been  enumerated,  by  which  it  was  supposed, 
that  malposition  of  the  child  might  be  discovered  antecedent  to  la- 
bour. An  unusual  shape  of  the  abdomen ;  some  peculiar  feeling 
of  which  the  mother  is  conscious,  and  which  she  has  not  felt 
in  any  former  pregnancy ;  greater  pain  or  numbness  in  one  leg 
than  in  the  other ;  a  sensation  of  the  child  rising  suddenly  towards 
the  stomach,  have  all  been  mentioned  as  indicating  this,  but  are  all, 
even  when  taken  collectively,  uncertain  tokens.  We  cannot  deter- 
mine the  presentation  until  labour  has  begun.  In  a  great  majority 
of  instances,  the  head,  during  the  end  of  gestation,  may  be  felt  rest- 
ing on  the  cervix  uteri;  but,  in  repeated  instances,  I  have  not  been 
able  to  distinguish  it  in  a  pregnancy  which  ended  in  natural  labour. 
Sometimes,  in  consequence  of  a  fall,  or  other  causes,  the  head 
.seems  to  recede,  but  afterwards  returns  to  its  proper  position. 


381 

When  labour  begins,  we  may  generally  distinguish  the  head  by  it* 
proper  character ;  but  if  it  lie  high,  and  especially  if  the  pelvis  be 
deformed,  we  may  not  find  it  always  easy  to  ascertain  the  presen- 
tation at  a  very  early  period.  In  such  cases,  it  is  of  great  conse- 
quence to  preserve  the  membranes  entire.  When  the  head  does 
not  present,  the  presentation  is  generally  more  distant,  and  longer 
of  being  distinctly  ascertained,*  the  lower  part  of  the  uterus  is  more 
conical,  and  the  tumour  formed  by  the  cranium  cannot  be  felt 
through  the  membranes  or  cervix  uteri :  when  the  finger  touches 
the  part  through  the  membranes,  it  very  easily  recedes,  or  seems 
to  rise  up.  If  the  child  lie  more  or  less  across  the  uterus,  the  os 
uteri  is  generally  long  of  being  fully  dilated,  the  membranes  pro- 
trude like  a  gut,  and  sometimes,  during  the  pains,  the  woman  com- 
plains of  a  remarkable  pushing  against  the  sides.  The  pains  are 
severe,  but  in  cross  presentation,  she  is  sensible  that  they  are  not 
advancing  the  labour. 

It  is  a  fact  well  ascertained,  that  although  the  head  have  been 
felt  distinctly  in  the  commencement  of  labour,  yet  when  the  mem- 
branes break,  it  may  be  exchanged  for  the  shoulder,f  or  some 
other  part.  On  this  account,  as  well  as  for  other  reasons,  it  is  al- 
ways proper  to  examine  immediately  after  the  membranes  have" 
given  way. 

ORDER  1.  PRESENTATION  OF  THE  BREECH, 

The  breech  is  distinguished  by  its  size  and  fleshy  feel,  by  the 
tuberosity  of  the  ischia,  the  shape  of  the  ilium,  the  sulcus  between 
the  thighs,  the  parts  of  generation,  and  by  the  discharge  of  meco- 

*  "When  the  presentation  is  long  of  being  felt,  we  have  been  advised  to  exa- 
mine the  woman  in  a  kneeling  posture,  or  even  to  introduce  the  hand  into  the 
vagina,  and  rupture  the  membranes.  The  last  advice  is  sometimes  useful,  as 
it  enables  us,  if  the  presentation  require  it,  to  turn  the  child  at  a  time  when  it 
can  be  easily  done.  But  this  is  not  to  be  hastily  practised,  nor  adopted  till  the  os 
uteri  be  well  dilated,  or  at  least  quite  dilatable. 

■j-  I  have  been  informed  of  a  case,  where  the  shoulder  was  exchanged  for  the 
head,  and  Jocrg  seems  to  have  met  with  the  same  circumstance.  Hist.  Partus, 
*.  90. 


382 

uium,  which  very  often  takes  place  in  the  progress  of  labour.** 
After  the  breech  has  descended  some  way  into  the  pelvis,  the  in- 
teguments may  become  tense  or  swelled,  so  as  to  make  it  resemble 
the  head.  Before  the  membranes  burst,  the  presentation  is  usually 
very  mobile,  and  bounds  up  readily  from  the  finger ;  but  in  some 
instances  it  is  from  the  first  firmly  pressed  down  in  the  pelvis,  and 
felt  through  the  uterus  very  much  resembling  the  head. 

Many  have  advised,  that  when  the  breech  presented,  the  feet 
should  be  brought  down  first ;  but  the  established  practice  now  is, 
when  the  pelvis  is  well  formed,  and  other  circumstances  do  not  re- 
quire speedy  delivery,  to  allow  the  breech  to  be  expelled  without 
any  interference,  until  it  has  passed  the  external  parts. 

The  breech,  and  consequently  the  body  of  the  child,  may  vary 
in  its  position  widi  regard  to  the  mother ',(/)  but  there  are  chiefly 
two  situations  requiring  our  attention,  because  the  rest  are  ulti- 
mately reduced  to  these.  First,  where  the  thighs  of  the  child  are 
directed  to  the  sacro-iliac  junction  of  the  pelvis ;  and  secondly, 
where  they  are  directed  to  the  acetabulum.  In  either  of  these 
cases,  delivery  goes  on  with  equal  ease,  until  the  head  comes  to 
pass.  Then,  if  the  thighs  have  been  directed  to  the  forepart  of  the 


*  A  discharge  of  liquor  amnii,  apparently  coloured  with  meconium,  is  no  proof 
that  the  breech  presents,  neither  is  it  a  sign  that  the  child  is  dead. 

C/J  Baudelocque  has  divided  the  presentations  of  the  breech  into  four  posi- 
tions.   In  the 

1st.  The  child's  back  is  towards  the  mother's  left  side,  and  a  little  forward. 
But  in  proportion  as  it  descends,  its  greatest  breadth  becomes  parallel  to  the 
antero-posterior  diameter  of  the  inferior  strait ;  the  left  hip  placing  itself  under  the 
pubes,  and  the  right  before  the  sacrum. 

2nd.  The  child's  back  is  towards  the  right  side  of  the  uterus,  and  a  little  for- 
ward ;  the  right  hip  placing  itself  under  the  arch  of  the  pubes,  the  left  being 
turned  towards  the  sacrum. 

3rd.  The  spine  of  the  child's  back  is  turned  directly  towards  the  umbilicus  of 
the  mother.    Although  it  is  allowed  seldom  to  descend  in  this  position. 

4th.  The  spine  of  the  child  is  towards  the  sacrum  of  the  mother,  and  its  abdo- 
men towards  the  anterior  and  middle  part  of  the  uterus  of  the  mother.  As  it  de- 
scends, the  breadth  from  one  hip  to  the  other  becomes  parallel  to  one  of  the  ob- 
lique diameters  of  the  pelvis. 


383 

pelvis,  the  face  will  also  be  turned  toward  the  pubis,  and  cannot 
clear  its  arch  so  easily  as  the  vertex. 

When  the  thighs  are  directed  to  the  back  part  of  the  pelvis,  wo 
find  that  the  process  of  delivery  is  as  follows  :  the  breech  general- 
ly descends  obliquely,  one  tuberosity  being  lower  than  the  other. 
The  lowest  one  follows  the  same  turns  as  the  vertex  does  in  na- 
tural labour,  and  observes  the  same  relation  to  the  axis  of  the  brim 
and  outlet  of  the  pelvis.  The  breech  is  expelled  with  one  side 
to  the  symphysis  of  the  pubis,  and  the  other  to  the  coccyx ;  and 
after  the  presenting  tuberosity  protrudes  under  the  arch  of  the  pu- 
bis, the  other  clears  the  perineum,  like  the  face  in  natural  labour. 
Whilst  the  breech  is  protruding,  it  gradually  turns  a  little  round, 
so  that  the  shoulders  of  the  child  come  to  pass  the  brim  diagonal- 
ly, the  diameter  from  the  acetabulum  to  the  sacro-iliac  junction 
being  the  greatest.  The  breech  being  delivered,  a  continuance  of 
the  pains  pushes  it  gradually  away,  in  the  direction  of  the  axis  of 
the  outlet,  until  the  legs  come  so  low  as  to  clear  the  vagina.  When 
this  takes  place,  the  head  is  generally  passing  the  brim  obliquely, 
the  face  being  turned  toward  the  sacro-iliac  junction ;  and  most 
frequently  the  arms  pass  along  with  it,  being  laid  over  the  ears. 
They  then  slip  down  into  the  vagina,  by  the  action  of  the  uterus, 
and  the  head  alone  enters  the  cavity  of  the  pelvis.  The  face  turns 
into  the  hollow  of  the  sacrum,  and  the  chin  tends  towards  the 
breast  of  the  child.  Then  it  clears  the  perineum,  which  slips  over 
the  face,  and  the  vertex  comes  last  of  all  from  under  the  pubis. 
If,  however,  the  chin  be  folded  down  on  the  breast,  before  the 
head  has  descended  into  the  pelvis,  then,  from  the  unfavourable 
way  in  which  it  enters  the  brim,  there  may  be  some  difficulty  to 
the  passage,  for  it  in  some  respects  resembles  a  presentation  of  the 
face.  The  hand  should  be  introduced,  and  the  face  pressed  up. 
In  one  case,  Dr.  Smellie  found  so  much  difficulty,  that  he  applied 
the  crotchet  on  the  clavicle. 

Now  the  management  of  this  labour  is  very  simple.  Whilst  the 
breech  is  coming  forth,  the  perineum  is  to  be  supported,  and  noth- 
ing more  is  to  be  done  till  the  knees  are  so  low  as  to  be  on  a  line 
with  the  fourchette.  If  they  do  not  naturally  bend,  and  the  feet 
slip  out,  the  finger  of  one  hand  is  to  be- employed  to  bend  the  leg 


384 

.gently,  and  bring  down  the  foot ;  the  knee,  in  this  process,  press- 
ing obliquely  on  the  abdomen  of  the  child.  But  whether  the  legs 
be  expelled  naturally,  or  be  brought  down,  we  must  carefully  pro- 
tect the  perineum  lest  it  should  be  torn  by  a  sudden  stroke  of  the 
leg  in  passing.  Next  the  cord  is  to  be  pulled  gently  down  a  lit- 
tle, to  make  the  circulation  more  free.  Thirdly,  we  attend  to  the 
arms  ;  if  these  do  not  descend  by  the  natural  efforts,  we  introduce 
a  finger,  and  gently  bring  down  first  one,  and  then  the  other,  using 
no  force,  lest  the  bone  should  break.  The  perineum  is  also  to  be 
guarded,  to  prevent  a  slap  of  the  arm  from  injuring  it.  Fourthly, 
if  the  head  do  not  directly  turn  down,  the  finger  is  to  be  carried 
up,  and  placed  upon  the  chin  or  in  the  mouth,  in  order  gently  to 
depress  it  toward  the  breast,  and  this  is  generally  sufficient.  To 
guard  the  perineum,  the  hand  must  be  applied  on  it,  and  the  body 
of  the  child  moved  near  the  thighs  of  the  mother,  that  the  vertex 
may  more  readily  rise  behind  the  pubis  whilst  the  face  is  passing. 
If  the  body  be,  on  the  contrary,  removed  farther  from  the  mother, 
and  nearer  the  operator,  the  head  can  neither  pass  so  easily  into 
the  pelvis,  nor  out  from  the  vagina.  In  a  natural  labour,  after  the 
head  is  expelled,  the  whole  body  should  be  allowed  to  be  slowly 
born  by  the  efforts  of  the  womb  alone.  But  in  breech  cases, 
should  the  process,  after  the  breech  is  expelled,  be  slow,  the  de- 
livery of  the  body  and  head  must,  by  the  means  I  have  related, 
be  accelerated,  lest  the  umbilical  cord  suffer  fatal  compression. 
The  first  symptom  of  danger  is  a  convulsive  jerk  of  the  body,  and 
if  the  head  be  not  speedily  brought  down,  the  child  will  be  lost. 
Should  delay  inevitably  arise,  we  must  try  to  bring  the  cord  to  the 
widest  part  of  the  pelvis.  But  even  although  all  pressure  could  be 
removed,  the  child  cannot  live  long,  if  it  be  not  delivered,  as  the 
function  of  the  placenta  is  soon  destroyed,  that  organ  being  often 
entirely  detached  from  the  womb,  following  the  head  whenever  it 
is  born. 

When  the  thighs,  in  breech  cases,  are  directed  to  the  pubis  or 
acetabulum,  then  the  face  cannot  turn  into  the  hollow  of  the  sa- 
crum. It  rests  for  some  time  on  the  pubis,  and  it  comes  out  with 
difficulty  under  the  arch ;  for  in  breech  and  footling  cases,  the 
face  is  generally  born  before  the  vertex.     Iu  order  to  prevent  this 


386 

difficulty,  it  will,  as  soon  as  the  breech  is  expelled  and  the  feet 
are  delivered,  be  proper  to  grasp  the  breech,  and  slowly  endeavour 
to  turn  the  body  round ;  but,  should  this  not  succeed,  or  not  have 
been  attempted  till  the  shoulders  have  come  down,  and  the  head 
is  about  to  pass  the  brim,  the  practice  is  dangerous,  and  the  neck 
may  be  materially  injured.  It  is,  in  this  case,  better  to  introduce 
a  finger,  and  press  with  it  on  the  head  itself,  endeavouring  thus  to 
turn  the  chin  from  the  acetabulum  to  the  sacro-iliac  junction  of 
the.  same  side.  If  the  position  be  not  rectified,  then  we  assist  the 
descent  by  depressing  the  chin,  and  gently  bringing  it  under  the 
pubis  ;  and  this  may  be  facilitated  by  pressing  the  vertex  upward 
and  backward,  and  making  it  turn  up  on  the  curve  of  the  sacrum, 
to  favour  the  descent  of  the  face.  We  must  be  careful  of  the  pe- 
rineum. 

When  the  pelvis  is  contracted  or  deformed,  it  will  be  prudent, 
at  an  early  stage  of  the  labour,  to  bring  down  the  feet.  But  if  this 
have  been  neglected,  then,  should  the  difficulty  of  delivery,  or  the 
length  of  time  to  which  the  labour  is  protracted,  require  it,  some 
insinuate  a  blunt  hook,  or  a  soft  ribband  over  one  of  the  groins, 
and  thus  extract  the  breech  ;  but  the  forceps  may  be  applied  with 
much  more  advantage.  When  the  resistance  is  slight,  the  insinu- 
ation of  the  fingers  over  the  groin,  may  sometimes  enable  us  to 
use  such  extracting  force,  as  at  least  excites  the  uterus  more  briskly 
to  expel.  Should  the  head  not  easily  follow  the  body,  we  must 
not  attempt  to  extract  it  by  pulling  forcibly  at  the  shoulders,  as  we 
may  thus  tear  the  neck,  and  leave  the  head  in  utero.*  The  cord 
is,  first  of  all,  to  be  freed  as  much  as  possible  from  compression ; 
then  we  gently  depress  the  shoulders  in  the  direction  of  the  axis 
of  the  brim,  at  the  same  time  that  we  with  a  finger  act  upon  the 
chin.  Should  this  not  succeed,  we  must  apply  the  finger  over  the 
head,  and  depress  in  the  proper  direction.     If  this  fail,  the  only 

*  La  Motte,  Chapman,  Smellie,  and  Perfect,  give  examples  of  the  head  being 
left  in  utero  without  the  body,  and  the  body  without  the  head.  There  are  chiefly 
two  sources  of  danger :  the  first  and  most  immediate  is  uterine  hemorrhage  ;  the 
second  is  the  consequence  of  putrefaction,  which  produces  sickness,  nausea,  fever, 
and  great  debility.  The  head  may  be  extracted,  by  fixing  a  finger  in  the  mouth, 
or  by  the  crotchet,  with  or  without  perforation. 

50 


386 

resource  is  to  open  the  cranium  above  or  behind  the  ear,  and  fix 
a  hook  in  the  aperture ;  but  this  is  not  to  be  done  until  we  have 
fully  tried  other  means,  and  by  that  time  the  child  will  be  dead. 

When  the  breech  presents,  and  parturition  is  tedious,  the  parts 
of  generation  are  often  swelled  and  livid.  When  the  parts  are 
merely  turgid  a  little,  and  purple  from  congestion  of  venous 
blood,  nothing  is  necessary  to  be  done.  But  when  inflammation 
takes  place,  it  is  more  troublesome,  for  being  of  the  low  kind,  it  is 
apt  to  end  in  gangrene.  Fomentations  are  useful,  but  often  spiri- 
tous  applications  succeed  best. 

ORDER  2.  OF  THE  INFERIOR  EXTREMITIES. 

Presentation  of  the  feet  is  known,  by  there  being  no  rounded 
tumour  formed  by  the  lower  part  of  the  uterus. (g)  The  mem- 
branes also  protrude  in  a  more  elongated  form  than  when  the  head 
or  breech  present.  The  presenting  part,  when  touched  during  the 
remission  of  the  pain,  is  felt  to  be  small,  and  affords  no  resistance 
to  the  finger.  When  the  membranes  break,  we  may  discover  the 
shape  of  the  toes  and  heel,  and  the  articulation  at  the  ankle. 
Sometimes  both  the  feet  and  the  breech  present.  Two  cir- 
cumstances contribute  to  an  easy  delivery ;  first,  that  the  toes 
be  turned  toward  the   sacro-iliac  junction  of  the  mother  j  and 

CgJ  Baudelocque  distinguishes  four  principal  positions  of  the  feet,  to  which 
he  considers  all  the  rest  may  be  referred.  Of  these  four  positions  he  constitutes 
as  many  species  of  labour.    In  the 

1st  position,  the  heels  answer  to  the  left  side  of  the  pelvis,  and  a  little  forward ; 
the  toes  to  the  right  side,  and  backward,  nearly  opposite  the  sacro-iliac  sym- 
physis. Above  that  symphysis  are  placed  the  breast  and  face  ;  while  the  back 
is  situated  under  the  anterier  and  left  lateral  part  of  the  uterus. 

In  the  2d  position,  the  heels  are  towards  the  right  side  of  the  pelvis,  and  the 
toes  to  the  left  and  a  little  backward.  The  trunk  and  head  are  so  situated,  that 
the  breast  and  face  answer  to  that  part  of  the  uterus  which  is  over  the  left  sacro- 
iliac symphysis,  and  the  back  to  the  anterior  and  right  lateral  part  of  that-w'scws. 

In  the  3d  position,  the  heels  are  turned  towards  the  pubes,  and  the  toes  to 
the  sacrum.  The  child's  back  is  under  the  anterior  part  of  the  uterus,  and  its 
breast  answers  to  the  lumbar  vertebra  of  the  mother. 

The  4th  position  is  exactly  the  reverse  of  the  3d  ;  the  child's  back  and  heels 
are  towards  the  posterior  part  of  the  uterus,  while  the  toes,  the  face  and  breast 
Are  under  its  anterior  part. 


387 

se6ondly,  that  both  feet  come  down  together.  The  best  practice 
is  to  avoid  rupturing  the  membranes  till  the  os  uteri  be  sufficiently 
dilated  ;  then  we  grasp  both  feet,  and  bring  them  into  the  vagina  ; 
or,  if  both  present  together  at  the  os  uteri,  we  may  allow  them  to 
come  down  unassisted.  In  either  case,  we  do  not  accelerate  the 
delivery  till  the  cord  is  in  a  situation  to  suffer  from  pressure,  that 
is,  till  the  knees  are  fully  protruded,  and  the  thick  part  of  the 
thighs,  near  the  breech,  can  be  felt;  then,  if  the  face  be  towards  the 
belly  of  the  mother,  we  grasp  the  thighs,  and  gently  turn  the  body 
round.  The  management  is  the  same  as  in  breech  cases.  There 
is  little  danger  of  the  feet  of  two  different  children  being  brought 
down  together,  as  twins  are  included  in  separate  membranes.  But 
as  the  case  is  possible,  it  is  proper  to  ascertain  that  the  feet  be  right 
and  left. 

Sometimes  a  knee  and  foot,  or  the  knees  alone,  present  ;(h)  and 
as  they  form  a  larger  tumour  than  the  feet,  they  may  at  first  be  ta- 
ken for  the  breech  or  the  head.  Generally  only  one  knee  presents, 
and  it  lies  obliquely,  with  its  side  on  the  os  uteri.  It  is  known  by 
its  shape,  and  the  flexure  of  the  joint.  Some  advise  that  the  case 
should  be  left  altogether  to  nature,  but  it  is  often  advantageous  to 
bring  down  the  feet. 

ORDER  3.  OF  THE  SUPERIOR  EXTREMITIES. 

When  the  shoulder  or  arm  presents,  the  case  has  the  general 
character  of  preternatural  presentations.^     The  round  tumour, 

(hj  Baudelocque  distinguishes  four  principal  positions  of  the  knees  also. 

In  the  first  position,  the  child's  legs,  which  are  always  bent  when  the  knees 
present,  are  towards  the  mother's  left  side,  and  the  thighs  towards  the  right  side. 

In  the  2d,  the  thighs  answer  to  the  left  side  of  the  pelvis,  and  the  legs  to  the 
right. 

In  the  3d,  the  anterior  part  of  the  thighs  is  turned  towards  the  sacrum  of  the 
mother,  and  the  legs  are  under  the  pubes. 

In  the  4th,  it  is  the  reverse,  the  child's  thighs  being  behind  the  pubes  of  the 
mother,  and  the  legs  placed  against  the  sacrum. 

fij  The  presentations  of  the  shoulder  are  divided  into  four  species  by  Baude- 
locque.   In  the 

1st.  The  side  of  the  neck  rests  on  the  edge  of  the  os  pubis,  and  the  side  of  the 


388 

formed  by  the  bead  in  natural  labour,  is  absent,  whilst  we  can  as- 
certain the  shape  and  connection  of  the  arm  and  shoulder.  A  shoul- 
der presentation  can  only  be  confounded  with  that  of  the  breech. 
But  in  the  former  case,  the  shape  of  the  scapula,  the  ribs,  the  sharp- 
ness of  the  shoulder  joint,  and  the  direction  of  the  humerus,  to- 
gether with  our  often  feeling  in  our  examination  either  the  hand  or 
neck,  will  be  distinguishing  marks.  In  the  latter,  the  round  shape 
and  greater  firmness  of  the  ischium,  the  size  of  the  thigh,  its  di- 
rection upwards,  and  its  lying  in  contact  with  the  soft  belly,  the 
spine  of  the  ilium,  the  parts  of  generation,  the  size  of  the  tubero- 
sity of  the  ischium,  and  the  general  shape  of  the  back  parts  of  the 
pelvis,  contribute  with  certainty  to  ascertain  the  nature  of  the  case. 
The  hand  and  arm  may  present  under  different  circumstances. 
The  original  presentation  may  have  been  that  of  the  shoulder,  but 
the  arm  may  have,  in  the  course  of  the  labour,  been  expelled  ;  or 
the  hand  may  rest  upon  the  os  uteri,  before  the  membranes  have 
broken  ;  or  the  fore  arm  may,  for  a  length  of  time,  lie  across  the  os 
uteri,  the  hand  not  being  protruded  for  some  hours.  Sometimes 
both  hands  are  felt  at  the  os  uteri,  and  even  both  arms  may  be  ex- 
pelled into  the  vagina ;  but  in  most  cases  this  does  not  happen,  un- 
less an  improper  conduct  be  pursued.  In  some  rare  instances,  the 
hands  of  twins  have  been  found  presenting  together,  both  sets  of 
membranes  having  given  way;  it  is  more  common  to  find  both  the 
hands  and  feet  of  the  same  child  presenting;  and  this,  next  to  the 


breast  over  the  sacrum,  so  that  the  fore  part  of  the  breast  is  towards  the  left 
iliac  fossa,  when  the  right  shoulder  presents,  and  towards  the  right  iliac  fossa 
when  it  is  the  left  shoulder. 

In  the  second  position,  the  side  of  the  neck  is  over  the  superior  edge  of  the 
sacrum,  and  the  side,  proper])'  so  called,  is  over  the  pubes  ;  the  breast  answers  to 
the  right  iliac  fossa,  when  the  right  shoulder  presents  and  vice  versa. 

In  the  third,  the  neck  and  the  head  rest  on  the  left  iliac  fossa,  while  the  side 
and  the  hip  are  over  the  right ;  so  that  the  back  is  placed  transversely  under  the 
anterior  part  of  the  uterus  when  it  is  the  right  shoulder,  and  on  the  posterior 
part  of  that  viscus,  when  it  is  the  left. 

The  child  is  also  placed  transversely  in  the  fourth  position  of  the  shoulder,  but 
the  head  lies  in  the  right  iliac  fossa,  and  the  lower  part  of  the  trunk  over  the  left; 
the  breast  is  under  the  anterior  part  of  the  uterus  when  it  is  the  right  shoulder, 
and  over  the  samtm  when  it  is  the  left. 


389 

presentation  of  the  feet  alone,  is  the  easiest  case  to  manage.*  It  is 
not  uncommon,  in  this  case,  to  find  the  cord  presenting  at  the  same 
time,  and  then,  by  delay,  the  child  may  be  lost. 

In  most  cases  where  the  superior  extremities  present,  the  feet 
of  the  child  are  found  in  the  fore  part  of  the  uterus,  toward  the  na- 
vel of  the  mother.  But  their  situation  may  be  known,  by  exam- 
ining the  presentation.  If  we  feel  the  shoulder,  we  know,  that  if 
the  scapula  be  felt  toward  the  sacrum,  the  feet  will  be  found  to- 
ward the  belly.  If  the  arm  be  protruded  into  the  vagina,  the  palm 
of  the  hand  is  found  in  pronation,  directed  toward  the  side  where 
the  feet  lie.  It  is  easy  to  know  which  hand  presents.  If  we  ex- 
amine with  the  right  hand,  we  shall  find,  that  if  the  palm  of  the 
child's  hand  be  taken  into  ours  in  a  state  of  pronation,  the  thumb 
of  the  right  hand,  or  the  little  finger  of  the  left  hand,  will  corres- 
pond to  our  thumb. 

In  these  preternatural  presentations,  die  ancients  were  acquaint- 
ed with  the  practice  of  turning,  and  delivering  the  child  by  the 
feet.  But  their  remarks  on  this  subject  formed  no  general  rule  of 
conduct;  on  the  contrary,  practitioners  were  almost  invariably  in 
the  habit  of  endeavouring  to  remove  the  presentation,  and  to  bring 
the  head  to  the  os  uteri.  Pare  was  among  the  first  who  advised 
turning  as  a  general  practice ;  but  even  his  pupil  Guillimeau  disre- 
garded the  rule,  and  left  it  to  Mauriceau  to  enforce  it,  both  by  rea- 
soning and  practice.f  There  may,  however,  be  cases,  where  it 
would  not  only  be  safe,  but  also  more  proper  to  resort  to  the  old 
practice,  although,  as  a  general  rule,  it  ought  to  be  abandoned. 
For  instance,  if  the  patient  be  known  usually  to  have  a  short  la- 
bour, if  the  pains  be  brisk,  the  os  uteri  dilated,  or  in  a  relaxed  and 
easily  dilatable  state,  the  liquor  amnii  retained,  and  the  child  move- 

*  It" the  uterus  be  firmly  contracted,  the  liquor  amnii  having  been  all  evacuat- 
ed, it  may  sometimes  be  necessary  to  carry  the  hand  up  to  the  knees,  to  change 
the  situation. 

f  Mauriceau  justly  observes,  that  although,  after  much  fatigue,  (the  water  hav- 
ing run  off,)  the  head  can  be  brought  to  the  os  uteri,  the  woman  may  not  have 
strength  to  finish  the  delivery. — In  a  case  mentioned  by  Dr.  Smellie,  the  patient 
died  of  flooding.— Joerg  still  admits  the  propriety  of  bringing  the  head,  when  it 
is  nearer  than  the  feet,  to  the  os  uteri,  or  the  foetus  is  so  placed,  that  the  feet  can 
-not,  without  difficulty  and  danger,  be  brought  down. 


390 

uble,  then  the  head  may,  without  any  difficulty,  or  much  irritation^ 
be  placed  in  the  proper  position,  with  a  fair  and  reasonable  chance 
of  success.  The  labour,  no  doubt,  is  slower  than  if  we  had  brought 
down  the  feet,  but  the  child  is  in  much  less  danger.  On  the  other 
hand,  if  the  liquor  amnii  have  been  evacuated,  or  any  irritation  at- 
tend the  rectification  of  the  presentation,  it  is  better  at  once  to 
bring  down  the  feet,  and  ensure  a  delivery,  safe  at  least  to  the  mo- 
ther. Were  the  head  in  such  a  case  made  to  present,  the  irritation 
employed  might  throw  the  uterus  into  spasmodic  action ;  or  it 
might  not  act  with  any  efficiency,  and  a  tedious  labour,  of  the  worst 
and  most  dangerous  kind,  might  be  the  consequence  of  this  injudi- 
cious practice,  whereby  both  parent  and  child  might  be  lost. 

We  should  be  careful,  in  all  cases,  not  to  rupture  the  membranes 
prematurely;  and  more  effectually  to  preserve  them  entire,  we 
must  prevent  exertion,  or  much  motion,  on  the  part  of  the  mother. 
As  soon  as  the  os  uteri  is  soft,  and  easily  dilatable,  the  hand  should 
be  introduced  slowly  into  the  vagina,  the  os  uteri  gently  dilated, 
and  the  membranes  ruptured.  The  hand  is  then  to  be  imme- 
diately carried  into  the  uterus,  and,  if  we  have  decided  on  turning, 
upwards  until  the  feet  are  found.  Both(k)  feet  are  to  be  grasped 
betwixt  our  fingers,  and  brought  down  into  the  vagina,  taking  care 
that  the  toes  are  turned  to  the  back  of  the  mother.  The  remain- 
ing steps  have  been  already  described.  This  operation  is  not 
very  painful  to  the  mother ;  it  is  easily  accomplished  by  the  ac- 
coucheur, and  it  is  not  more  hazardous  to  the  child  than  an  origi- 
nal presentation  of  the  feet.  But  it  is  necessary,  in  order  to  ren- 
der this  assertion  correct,  that  the  operation  be  undertaken  before 
the  liquor  amnii  be  evacuated ;  and  it  is  of  importance  to  fix  upon 
a  proper  time.  We  are  not  to  attempt  the  introduction  of  the 
hand  whilst  the  os  uteri  is  hard  and  undilated ;  this  is  an  axiom  in 
practice ;  on  the  other  hand,  we  are  not  to  delay  until  the  os  uteri 
be  dilated  so  much,  as  to  be  apparently  sufficient  for  the  passage 


(~kj  It  is  not  absolutely  necessary  that  both  feet  should  be  found  and  grasped, 
in  the  first  instance ;  it  will  be  sufficient  to  find  and  bring  down  one,  if  both 
cannot  be  easily  reached,  the  second  foot,  with  proper  management,  (to  be 
hereafter  direeted,)  will  soon  follow. 


391 

of  a  bulky  body.  In  the  cases  now  under  consideration,  the  os 
uteri  does  not  dilate  so  regularly,  and  to  so  great  a  degree,  before 
the  membranes  break,  as  when  the  head  presents.  If  we  wait  in  this 
expectation,  the  membranes  will  give  way  before  we  are  aware. 
If  the  os  uteri  be  dilated  to  the  size  of  half  a  crown,  thin  and  lax, 
the  delivery  ought  not  to  be  delayed,  for  every  pain  endangers  the 
rupture  of  the  membranes.  If  they  do  give  way,  we  are  imme- 
diately to  introduce  the  hand,  and  will  still  find  the  operation  easy, 
for  the  whole  of  the  water  is  not  discharged  at  once,  nor  does  the 
uterus  immediately  embrace  the  child  closely.  If  the  liquor 
amnii  have  been  discharged  in  considerable  quantity  previous  to 
labour,  or  if  the  membranes  have  burst  at  the  commencement  of 
it,  when  the  os  uteri  is  firm  and  small,  we  must,  by  a  recumbent 
posture,  try  still  to  preserve  a  portion  of  the  waters,  till  the  orifice 
will  permit  delivery.  The  introduction  of  the  hand  into  the  va- 
gina and  os  uteri  may  be  rendered  easier,  and  less  painful,  by  pre- 
viously dipping  it  in  oil  or  linseed  tea,  or  any  other  lubricating 
substance. 

But  if  the  water  have  been  long  evacuated,  then  the  fibres  of 
the  uterus  contract  strongly  on  the  child,  the  presentation  is  forced 
firmly  down,  and  the  whole  body  is  compressed  so  much,  that  the 
circulation  in  the  cord  frequently  is  impeded,  and,  if  the  labour 
be  protracted,  the  child  may  be  killed.  This  is  a  very  trouble- 
some case,  and  requires  great  caution.  If  the  pains  be  frequent, 
and  the  contraction  strong,  then  all  attempts  to  introduce  the  hand, 
and  turn  the  child,  must  not  only  produce  great  agony,  but,  if  ob- 
stinately persisted  in,  may  tear  the  uterus  from  the  vagina,  or 
lacerate  its  cervix  or  body.  After  a  delay  of  some  hours,  however, 
the  uterus  may  be  less  violent  in  its  action,  but  it  is  better  at  once 
to  moderate  it  by  art.  Copious  blood-letting,  certainly,  has  a 
power  in  many  cases  of  rendering  turning  easy,  but  it  impairs  the 
strength,  and  often  retards  the  recovery.  If  the  patient  be  restless 
and  feverish,  it  may,  to  a  certain  extent,  be  necessary  and  proper ; 
but  if  not,  we  shall  generally  succeed,  by  giving  a  powerful  dose 
of  tincture  of  opium,  not  less  than  sixty  or  eighty  drops.  Previous 
to  this,  the  bladder  is  to  be  emptied,  lest  it  should  be  ruptured 
during  the  operation;  and,  if  necessary,  a  clyster  is  to  be  adminis- 


392 

tered.  The  patient  is  then  to  be  left,  if  possible,  to  rest.  Some- 
times in  half  an  hour,  but  almost  always  within  two  hours  after  the 
anodyne  has  been  taken,  the  pains  become  so  far  suspended,  as  to 
render  the  operation  safe,  and  perhaps  easy.  Our  first  object  is 
to  get  the  hand  into  the  uterus  ;  and  for  this  purpose,  we  must 
raise  up  the  shoulder  a  little,  working  the  fingers  past  it,  by  slow, 
cautious,  but  steady  efforts.  The  cervix  often  contracts  spasmo- 
dically round  the  presentation,  and  is  the  chief  obstacle  to  the 
delivery,  but  the  opiate  generally  allays  this.*  Sometimes  our 
efforts  renew  the  pains,  which,  although  they  may  not  prevent  the 
operation,  make  it  more  painful,  and  cramp  and  benumb  the  hand. 
Having  passed  the  hand  beyond  the  cervix,  we  carry  it  on  betwixt 
the  body  of  the  child  and  the  surface  of  the  uterus,  which  is  felt 
hard  and  smooth,  from  the  tonic  or  permanent  action  of  the  fibres, 
until  we  reach  the  feet,  both  of  which,  if  possible,  we  seize  and 
bring  down  ;  but  if  we  cannot  easily  find  both,  one  is  to  be  brought 
down  into  the  vagina,  and  retained  there. (I)  The  child  will  be 
born,  with  the  other  folded  up  on  the  belly.  In  bringing  down 
the  feet,  as  well  as  in  carrying  up  the  hand,  we  must  not  act  dur- 
ing a  pain,  but  should  keep  the  hand  flat  on  the  child  ;  a  con- 
trary practice  is  very  apt  to  lacerate  the  uterus.  Before  introducing 
the  hand,  we  must  ascertian,  by  examining  the  presentation,  which 
way  the  feet  lie,  that  we  may  proceed  directly  to  the  proper 
place.  We  must  also  consider,  whether  we  shall  succeed  best 
with  the  right  or  the  left  hand.  If  the  right  shoulder  or  arm  pre- 
sent, some  have  made  it  a  rule  to  deliver  with  the  left  hand,  others 
with  the  right ;  but  much  must  depend  on  the  dexterity  of  the 
operator,  and  the  position  of  the  woman.  The  most  common 
position  is  the  same  as  in  natural  labour.  Sometimes  we  may 
find  it  useful  to  make  the  woman  lie  forward  on  the  side  of  the 
bed*  with  her  feet  on  the  ground,  and  to  place  ourselves  behind 
her. 


*  The  spasm  may  yield  rather  suddenly  to  the  hand,  as  if  rupture  of  the  fibres 
had  taken  place.  I  was  informed  of  one  case  of  this  kind,  but  the  womb  was  en- 
tire, and  no  bad  symptoms  came  on. 

flj  By  means  of  a  noose  applied  round  the  ancle. 


393 

When  the  hand  and  arm  have  heen  protruded,  and  the  shoulder 
forced  down  in  the  vagina,  it  has  been  the  practice  with  many,  be- 
fore attempting  to  turn,  to  return  the  arm  again  within  the  uterus ; 
and  when  this  was  impracticable,  it  has  been  torn  or  cut  off,  (m) 
especially  if  the  child  was  supposed  to  be  dead.  Others  advise, 
that  we  should  not  attempt  to  reduce  the  arm ;  nay,  even  that  we 
could,  in  difficult  cases,  facilitate  the  operation,  by  bringing  down 
the  other  arm,  in  order  to  change,  to  a  certain  degree,  the  position 
of  the  child.  So  far  from  it  being  necessary  to  replace  the  arm, 
we  shall  sometimes  find  advantage  from  taking  hold  of  it  with  one 
hand,  whilst  we  introduce  the  other  along  it ;  as  the  parts  are 
thus  a  little  stretched,  and  it  serves  as  a  director  by  which  we  slrp 
into  the  uterus. 

By  the  means  pointed  out,  and  by  a  steady,  patient  conduct, 
we  may,  in  almost  every  instance,  succeed  in  delivering  the  child. 
But  it  must  be  acknowledged,  that  in  some  cases,  from  neglect  or 
mismanagement,  the  woman  is  brought  into  great  danger,  or  may 
even  be  allowed  to  die  undelivered.  This  catastrophe  proceeds 
sometimes  from  mere  exhaustion,  or  from  inflammation,  but  often- 
er,  I  apprehend,  from  rupture  of  the  uterus ;  or  in  a  neglected 
ease,  so  much  irritation  may  be  given  to  the  system,  as  well  as  to 
the  parts  concerned  in  parturition,  that  although  the  delivery  be 
easily  accomplished,  the  woman  does  not  recover,  but  dies,  either 
from  pulmonic  or  abdominal  inflammation,  or  fever,  or  flooding. 
Moreover,  such  tedious  cases  generally  end  unfavourably  far  the 
child. 

When  turning  has  not  been  practicable,  if  the  child  was  sup- 
posed to  be  alive,  the  os  uteri  has  been  cut,  or  the  caesarian 
operation  has  been  proposed  and  practised.*     If  dead,  it  has  been 

(~mj  We  would  strenuously  dissuade  from  unnecessarily  mutilating  the  foetus, 
even  under  the  supposion  of  its  death.  We  have  known  the  child  born  with 
symptoms  of  life,  even  after  the  head  has  been  opened,  and  the  greatest  portion 
of  the  brain  evacuated  ;  and  born  alive,  after  its  death  had  been  considered  as 
certainly  ascertained.  It  can  seldom,  if  ever,  be  necessary  to  take  off  the  arm  to 
facilitate  the  operation  of  turning. 

*  Vide  memoir  by  M,  Baudelocque,  in  Recueil  Period.  Tome  V.  table  1,  cas*J 
5  and  \5. 

51 


394 

extracted,  by  pulling  down  the  breech  with  a  crotchet;*  and 
sometimes,  in  order  to  assist  delivery,  the  body  has  been  muti- 
lated,! or  the  head  opened  with  the  perforator.  It  is  in  general 
sufficient  to  carry  the  finger  between  the  perineum  and  the  thorax 
to  the  abdomen,  pierce  it,  and  either  by  means  of  the  finger  or  a 
hook  fixed  on  the  pelvis,  it  may  be  pulled  down.  This  ought  al- 
ways to  be  done,  when,  on  the  one  hand,  the  presentation  cannot 
be  raised  to  admit  of  turning ;  nor,  on  the  other,  is  there  any  ap- 
pearance of  the  process  immediately  to  be  described,  under  the 
name  of  spontaneous  evolution,  taking  place. 

When  the  child  has  been  small  or  premature,  it  has  happened 
that  the  arm  and  shoulder  have  been  forced  out  of  the  vagina,  and 
then,  by  pulling  the  arm,  the  delivery  has  been  accomplished.^  In 
other  cases,  the  child  has  been  expelled  double.  In  a  greater  num- 
ber of  instances,  a  spontaneous  evolution  or  turning  of  the  child 
has  taken  place,  and  the  breech  has  been  expelled  first.  The  ac- 
tion of  the  uterus  is  exerted  in  the  direction  of  its  long  axis,  and 
therefore  tends  to  push  its  contents  through  the  os  uteri.  The  child 
forms  an  ellipse ;  and  either  in  natural  labour,  or  presentation  of 
the  breech,  the  long  axis  of  the  ellipse  corresponds  to  the  long  axis 
of  the  uterus.  But,  in  a  shoulder  presentation,  the  axis  of  the  el- 
lipse lies  obliquely  with  regard  to  that  of  the  uterus,  or  to  the  di- 
rection of  the  force  ;  and  therefore  the  continued  action  of  the 
uterus  may  tend,  by  operating  on  the  side  of  the  ellipse,  to  depress 
the  upper  end,  and  force  it  gradually  into  the  pelvis.  Dr.  J.  Ha- 
milton justly  observes,  that  the  evolution  can  only  take  place  when 
the  action  of  the  uterus  cannot  be  exerted  on  the  presenting  part, 
or  where  that  part  is  so  shaped  that  it  cannot  be  wedged  in  the  pel- 

*  Pen,  in  one  case  where  both  arms  were  protruded,  applied  a  fillet  over  the 
breech  to  bring  it  down.  Pratique,  p.  412. — Smellie,  in  1722,  brought  down 
the  breech  with  the  crotchet.  Col.  35.  case  3. — Gifford  did  the  same  in  1725. 
Case  3. 

f  Vide  Perfect,  Vol.  I.  p-  351. — Dr.  J.  Hamilton's  Cases,  p.  104.  He  found  it 
necessary  to  separate  three  of  the  vertebra:. — Dr.  Clarke  twisted  off  the  arm,  and 
perforated  the  thorax  freely.  At  the  end  of  36  hours  the  foetus  was  expelled  dou- 
ble.    Med.  and  Phys.  Jour.  Vol.  VIII.  394. 

t  Gifford,  case  211  ;  and  Baudelocque  L'Art,  §  1530,  in  a  note. — In  Mr.  GaD- 
dincr's  cas^tlie  head  followed  the  shoulders.     Med.  Comment.  V.  307. 


395 

vis.  It  may  also  be  added,  as  a  requisite,  that  the  uterus  contract 
efficiently,  and  not  spasmodically.  This  occurrence  was  first  of  all 
noticed,  I  believe,  by  Schoenheider  ;*  but  Dr.  Denmanf  was  the 
first  who,  in  this  country,  called  the  attention  of  practitioners  to  it. 
He  collected  no  less  than  thirty  cases,  but  in  these  only  one  child 
was  born  alive.  It  does  not  appear  that  the  child  being  large,  is  an 
obstacle  to  the  deli  very  .J 

A  diversity  of  opinion  has  prevailed  as  to  the  mode  in  which 
expulsion  takes  place.  Dr.  Denman  supposed  that  the  lower  ex- 
tremities descended  during  a  pain,  and  made  room  for  the  upper, 
which  were  received  into  the  uterus  as  the  others  came  down,  till, 
the  body  turning  round  on  its  axis,  the  breech  was  expelled,  "  as 
in  an  original  presentation  of  that  part."  This  was  disputed  by  Dr. 
Douglas,  who  maintained  that  it  was  impossible  for  the  upper  ex- 
tremities to  mount  up  into  the  contracting  uterus;  and  that  there- 
fore no  part  of  the  child,  which  once  protruded,  ever  receded;  and 
consequently  the  process  is  not  that  of  spontaneous  turning,  but  that 
of  expelling  the  child  double.  According  to  him  the  shoulder  is 
forced  lower  by  strong  pains ;  the  clavicle  lies  under  the  arch  of 
the  pubis ;  the  ribs  press  out  the  perineum,  and  then  appear  at  the 
orifice  of  the  vagina.  As  the  expulsion  goes  on,  the  clavicle  is  found 
on  the  pubis,  and  the  acromion  rises  to  the  top  of  the  vulva.  Pre- 
sently the  arm,  shoulder,  and  one  side  of  the  chest,  are  protruded, 
and  the  breech  has  got  into  the  hollow  of  the  sacrum.  By  farther 
efforts  the  breech  and  extremities  are  expelled,  but  neither  the  arm 
nor  the  shoulder  ever  retire. 

Dr.  Kelly  agrees  with  Dr.  Denman,  as  to  the  existence  of  an 
actual  revolution  or  turning  of  the  child ;  but  differs  from  him  in 
maintaining  that  the  original  presentation  can  only  recede,  not  du- 
ring the  action  of  the  uterus,  but  during  its  relaxation.  The  breech, 
or  upper  end  of  the  ellipse,  he  supposes,  is  pressed  down  by  the 

*  Acta  Havn.  Tom.  II.  art.  xxiii. 

f  Lond.  Med.  Jour.  Vol.  V.  p.  64. — See  also  case  by  Mr.  Outhwait,  in  New 
Lond.  Med.  Jour.  Vol.  II.  p.  172. — Mr.  Simmons  Med.  Facts  and  Obs.  Vol.  I.  p. 
76.— Perfect's  cases,  II.  367. — Med.  and  Phys.  Journ.  Vol.  III.  p.  5.— and  Medico- 
Chirurgical  Review,  Vol.  I.  second  series. 

i  Mr.  Hey's  case,  in  Lond.  Med.  Jour.  Vol.  V.  p.  305. 


396 

action  of  the  uterus  ,  and  then,  by  the  elasticity  of  the  child,  the 
shoulder,  or  presenting  part,  goes  up  the  moment  the  uterus  re- 
laxes. There  is  much  apparent  justice  in  the  observation  ;  but 
nevertheless  it  is  not  free  from  objection.  Every  one  who  has  had 
his  hand  in  the  uterus,  in  order  to  turn  the  child,  must  know,  that 
the  inner  surface  feels  hard,  smooth,  and  polished;  and  that  hav- 
ing laid  hold  of  the  feet,  it  requires  very  little  effort  during  a  pain 
to  draw  them  down  ;  as  the  breech  was  pressed  on  in  the  direction 
from  the  fundus  to  the  os  uteri.  If  every  part  of  the  uterus  acted 
alike,  and  there  were  no  os  uteri,  it  is  evident  that  the  whole  child 
should  be  equally  squeezed,  and  its  superficies  pressed  more  close- 
ly to  the  centre;  if  there  be  an  opening  in  the  contracting  cavity, 
there  must  be  a  tendency  to  press  the  contents  towards  that :  and 
this  is  the  principle  on  which  natural  labour  is  founded.  But  if  the 
contents  cannot  pass  through  this  opening,  or  through  the  pelvis, 
as  is  the  case  in  presentation  of  the  arm ;  then,  either  the  uterus 
must,  after  exhausting  itself,  cease  to  act,  or  its  fibres  will  give  way, 
or  if  the  presentation  be  placed  in  so  oblique  and  favourable  a 
mode  as  to  permit  of  it,  the  under  end  of  the  ellipse,  or  the  pre- 
senting part,  will  glide  up  along  the  smooth  uterus,  in  proportion 
as  the  upper  end  is  depressed  :  and  there  is  nothing  more  impos- 
sible, so  far  as  uterine  contraction  is  concerned,  in  the  child  re- 
volving during  the  action  of  the  uterus,  by  the  efforts  of  the  womb 
on  the  upper  end  of  the  ellipse,  than  that  we  should,  during  the 
uterine  contraction,  find  the  shoulders  with  facility  go  up,  merely 
by  drawing  gently  at  the  feet.  The  action  of  the  uterus,  if  the 
head  be  placed  obliquely,  and  the  presenting  part,  or,  what  is  of 
more  consequence,  the  head  within  the  uterus,  be  placed  in  such 
a  manner  as  to  allow  it  to  glide  as  on  an  inclined  plane,  may  assu- 
redly make  the  child  revolve.  The  steps  in  this  process  are  very 
distinct :  first,  the  presentation  is  forced  as  low  as  the  uterus  can 
bring  it ;  that  is,  the  shoulder  is  brought  to  the  perineum  :  second, 
when  it  can  pass  no  further,  the  strong  action  of  the  uterus,  pres- 
sing down  the  other  end  of  the  child,  makes  it  turn  on  the  resisting 
part,  as  on  a  pivot,  whilst  the  head  slides  up  along  the  inclined 
plane.  This  may  farther  be  aided  by  the  elasticity  of  the  child, 
operating  during  the  relaxation  of  the  uterus,  in  making  the  pre- 


397 

sentation  ascend.  But  this  cannot  be  the  only  cause,  nor  can  the 
objection  of  Drs.  Douglas  and  Kelly  be  well  founded,  otherwise 
the  process  never  could  take  place  with  that  rapidity  which  it  some- 
times does  :  indeed  it  is  never  long  when  it  begins ;  it  may  be  long 
of  commencing,  but  it  is  soon  accomplished.  In  one  of  Dr.  Den- 
man's  cases,  (the  third)  he  says,  "  the  exertions  of  the  mother 
were  wonderfully  strong.  I  sat  down  whilst  she  had  two  pains,  by 
the  latter  of  which  the  child  was  doubled,  and  the  head  expelled." 
Is  this  compatible  with  the  theory  of  the  child  not  receding  during, 
the  action  of  the  uterus  ?  Either  the  presenting  part  did  not  re- 
cede at  all,  as  is  maintained  to  be  the  case  invariably  by  Dr.  Doug- 
las ;  or  it  must  have  receded  during  the  single  pain  which  effected 
the  process.  We  expect  the  evolution  to  take  place  when  the 
shoulder  has  protruded  at  the  os  externum,  the  perineum  become 
more  distended  by  the  body  of  the  child,  the  pains  are  strong,  and 
not  spasmodic,  but  universal,  and  there  is  a  tendency  in  the  shoul- 
der to  move  forward,  and  the  breech  or  trunk  to  descend.  When 
turning  is  impracticable  or  dangerous,  and  nature  appears  to  have 
begun  this  process,  it  is  generally  hurtful  to  interfere.  If  any  aid 
is  to  be  given,  the  direction  in  which  the  shoulder  should  be  made 
to  move,  may  be  learned  from  the  detail  of  the  progress  of  the  evo- 
lution. 

A  knowledge  of  this  fact  does  not  exonerate  us  from  making 
attempts  to  turn  ;  for  although  a  considerable  number  of  cases  are 
recorded  where  it  has  taken  place,  yet  these  are  few  in  proportion 
to  the  number  of  presentations  of  the  shoulder.  In  this  city,  [Glas- 
gow] which  contains  not  less  than  150,000  inhabitants,  I  cannot 
learn  that  more  than  one  case  of  spontaneous  evolution  has  taken 
place,  though  some  women  have  either  died  undelivered,  or  have 
not  been  delivered  until  it  was  too  late  to  save  them.* 

*  Delivery  by  spontaneous  evolution  is  a  very  rare  occurrence.  But  that  it  occa- 
sionally happens  is  proved  beyond  suspicion  by  the  cases  recorded  by  Dr.  Den- 
man  and  other  respectable  practitioners.  Considering  the  difficulty  and  eTen 
danger  often  incident  to  turning,  it  is  certainly  important  to  know  how  to  distin- 
guish those  particular  cases  in  which  this  curious  resource  of  nature  will  proba- 
bly be  successfully  exerted.  To  warrant  such  an  expectation,  it  must  clearly  ap- 
pear that  the  uterine  action,  instead  of  operating  on  the  presenting  part,  fixing  it 


398 

Sometimes  the  arm  presents  along  with  the  head,  and  this  can 
only  render  delivery  tedious  or  difficult,  by  encroaching  on  the  di- 
mensions of  the  pelvis.  This  case  does  not  require  turning  ;  but 
if  we  can,  we  should  return  the  arm  beyond  the  head ;  if  we  can- 
not we  may  succeed  in  bringing  it  to  a  place  where  it  will  not  in- 
terfere much  with  the  passage  of  the  head.  In  a  case  most  pro- 
bably at  first  of  this  description,  the  arm  had  protruded  as  in  an 
ordinary  presentation  of  the  upper  extremity,  and  the  shoulder  had 
descended  as  low  as  the  os  externum.  Mr.  Wansbrough,  carrying 
his  finger  from  the  presentation  along  by  the  curve  of  the  sacrum, 
felt  the  chin  of  the  child,  the  face  presenting  within  the  pelvis,  and 
the  occiput  reflected  against  the  vertebrae  of  the  child.  Very  strong 
pains  had  no  effect  in  propelling  the  child ;  but  delivery  was  ef- 
fected by  means  of  the  long  forceps.* 

Sometimes  the  head  is  placed  pretty  high,  being  retained  by  a 
spasmodic  contraction  of  a  band  of  fibres  round  it,  and  the  arm  is 
the  only  presentation  which  can  be  felt,  until  the  hand  be  introduc- 
ed. Opiates,  in  this  case,  may  be  of  service.  We  must  never  at- 
tempt by  force  alone  to  destroy  the  stricture,  in  order  either  to  re- 
turn the  arm  or  bring  down  the  head. 

Occasionally  both  a  hand  and  the  feet  have  been  found  present- 
ing with  the  head,  or  the  feet  and  head  present.  In  such  cases, 
we  can,  if  necessary,  bring  down  the  feet  altogether,  and  this  is  in 
general  proper. 

Besides  these  presentations,  we  may  meet  with  the  back  part 
of  the  neck,  and  the  upper  part  of  the  shoulder  ;  or  the  nape  of 
the  neck  alone  ;  or  the  throat.(n)  These,  which  are  very  rare, 
require  turning.  They  are  recognised  by  their  relation  to  the 
head  and  shoulders. 

more  closely  in  the  pelvis,  has  the  contrary  effect  of  displacing  it,  and  gradually 
bringing  it  out  of  the  pelvis.  But,  if  we  are  convinced  after  a  careful  examina- 
tion that  there  is  no  tendency  to  spontaneous  evolution,  we  should  proceed  to  turn 
the  child,  as  in  proportion  to  the  delay  of  the  operation  is  commonly  the  hazard 
attending  it.     C. 

*  Med.  Repository.  Vol.  XIII.  p.  8.  * 

(n)  Of  each  of  these,  Baudelocque  has  constituted  four  varieties  of  presenta- 
tions ;  for  a  synopsis  of  which  we  must  refer  to  the  table,  which  the  reader  will 
find  at  the  end  of  this  volume. 


399 


ORDER  4.  OF  THE  TRUNK. 

The  hips,  back,  belly,  breast,  or  sides,  may,  though  very  rare  y. 
present,  the  child  lying  more  or  less  transversely.(oJ  The  hip  js 
sometimes  taken  for  the  head,*  but  is  to  be  distinguished  by  the 
shape  and  relations  of  the  ilium.  In  all  the  other  cases,  the  pre- 
sentation remains  long  high  ;  but  when  the  finger  can  reach  it,  the 
precise  part  may  be  ascertained  by  one  who  is  accustomed  to  feel 
the  body  of  a  child.  If  the  child  lie  transversely,  it  may  remain 
long  in  the  same  position,  and  the  woman  may  die  if  it  be  not 
turned.  But  if,  as  is  more  frequently  the  case,  it  be  placed  more 
or  less  obliquely,  then,  if  the  pains  continue  effective  and  regular, 
either  the  breech  or  the  shoulder  will  be  brought  to  the  os  uteri, 
according  as  the  original  position  favoured  the  descent  of  one  or 
other  end  of  the  ellipse  formed  by  the  child.  In  these  presenta- 
tions, the  hand  should  be  introduced,  to  find  the  feet,  by  which  the 
child  is  to  be  delivered.  But,  this  rule  is  not  absolute  with  re- 
gard to  the  presentation  of  the  hip,  which  only  renders  labour  te- 
dious. 

ORDER  5.  OF  THE  FACE,  &c. 

The  child  may  present  the  head,  and  yet  it  may  be  improperly 
•situated,  and  give  rise  to  painful  and  tedious  labour. 

1st.  The  forehead,  instead  of  the  vertex,  may  be  turned  to  the 
acetabulum.^)  In  this  case,  the  presentation  is  felt  in  the  first 
stage  high  up,  smooth,  and  flatter  than  usual.  In  a  little  longer, 
we  discover  the  anterior  fontanelle,  and  the  situation  of  the  sutures. 
By  degrees  the  head  enters  the  cavity  of  the  pelvis,  the  vertex 

(o)  Of  each  of  these  presentations  there  are  also,  according  to  Baudelocque, 
four  varieties  ;  for  an  enumeration  of  which,  the  reader  is  referred  to  the  table 
at  the  close  of  the  volume. 

•  La  Motte  was  of  opinion  that  no  part  resembled  the  head  more  than  the  hip. 
Vide  Obs.  283  and  284. 

(/»)  This  includes  the  fourth  and  fifth  presentations  of  the  vertex,  according1 
to  the  division  of  Baudelocque,  and  have  already  been  explained  in  our  note  on 
the  Classification  of  Labours,  Book  II.  chap.  1. 


400 

being  turned  into  the  hollow  of  the  sacrum  ;  and  by  continuance 
of  the  pains,  the  forehead  either  turns  up  within  the  pubis,  and 
the  vertex  passes  out  over  the  perineum  ;  or  the  face  gradually  de- 
scends, and  the  chin  clears  the  arch  of  the  pubis,  the  vertex  turn- 
ing up  within  the  perineum  towards  the  sacrum  till  the  face  is  born. 
The  first  is  the  usual  process  in  this  presentation ;  all  the  steps  of 
the  labour  are  tedious,  and  often,  for  a  considerable  period,  the 
pains  seem  to  produce  no  effect  whatever.  In  the  last  stage,  the 
perineum  is  considerably  distended,  and  it  requires  care  and  pa- 
tience to  prevent  laceration.  This  presentation  is  difficult  to  be 
ascertained,  at  an  early  stage,  before  the  membranes  burst ;  and 
sometimes  the  duration  of  the  labour  is  attributed  to  weakness  of 
the  uterine  action,  and  not  to  the  position  of  the  head.  If  it  be 
discovered  early,  it  is  certainly  proper  to  rupture  the  membranes, 
and  turn  the  vertex  round  ;  a  proceeding  which  is  easily  accom- 
plished, and  which  prevents  much  pain  and  fretfulness.  If  this 
opportunity  be  lost,  we  may  still  give  assistance.  Dr.  Clarke  says, 
that,  in  thirteen  out  of  fourteen  cases,  he  succeeded  in  turning 
round  the  vertex,  by  introducing  either  one  or  two  fingers  between 
the  side  of  the  head  near  the  coronal  suture,  and  the  symphysis  of 
the  pubis,  and  pressing  steadily,  during  a  pain,  against  the  parietai 
bone.(q)  Of  the  advantage  of  this  practice,  I  can  speak  from  my 
own  observation ;  and  I  have,  even  when  the  head  had  descended 
So  low  as  to  have  the  nose  on  a  line  with  the  arch  of  the  pubis, 
succeeded  in  turning  the  face  round  to  the  hollow  of  the  sacrum 
with  great  promptitude,  and  with  so  much  facility,  that  the  patient 
did  not  know  that  I  was  doing  more  than  making  an  ordinary  ex- 
amination.    Some  have  advised,  that  we  should  keep  up  the  fore* 

{f/)  The  editor  can  also  unite  from  his  own  experience,  in  recommending  the 
attempt  at  altering  and  correcting  this  malposition  of  the  head,  as  above  recom- 
mended ;  it  has  often  proved  successful  in  his  own  practice.  It  will  be  found 
that  this  mode  of  proceeding  was  first  inculcated  by  Baudelocque,  from  ob- 
serving that  nature  herself  sometimes  obviated  difficulties,  and  accelerated  the 
termination  of  the  labour,  by  converting  the  fourth  position  into  the  second, 
and  the  fifth  into  the  first ;  or,  in  bringing  the  posterior  fontanelle  from  the 
right  or  left  sacroiliac  symphysis,  to  the  right  or  left  acetabulum.  Vide  Art 
des  Ajccouchemensi 


401 

head  during  a  pain,  to  make  the  vertex  descend  ;  or  that  we  should, 
with  the  finger,  depress  the  occiput. 

The  fontanclle,  or  crown  of  the  head,  may  also  present,  although 
the  face  be  turned  to  the  sacro-iliac  junction.  In  this  case  it  is  felt 
early,  and,  by  tracing  the  coronal  suture,  we  may  ascertain  whether 
the  frontal  bones  lie  before  or  behind.  It  is  a  much  more  un- 
common presentation  than  that  noticed  above.  The  labour  is,  at 
first,  a  little  slower  than  in  a  natural  presentation,  but,  by  degrees, 
the  head  becomes  more  oblique,  the  vertex  descending ;  and  this 
may  be  assisted,  by  supporting  the  forehead  with  the  finger  during 
a  pain.  Should  any  untoward  accident  require  the  delivery  to  be 
accelerated,  we  have  been  advised  to  turn  the  child,  and,  in  doing 
so,  to  use  the  left  hand,  if  the  occiput  lie  on  the  left  acetabulum, 
and  vice  versa.     But  this  operation  can  seldom  be  requisite. 

The  crown  of  the  head  may  also  present  with  the  face  to  the 
pubis  or  the  sacrum,  but  these  positions  are  extremely  lare.(r) 
In  time,  the  head  will  generally  become  more  diagonal,  and  de- 
scend obliquely,  but  we  ought  not  to  trust  to  this.  We  should 
rectify  the  position,  for  it  is  by  no  means  difficult  to  move  the  head 
with  the  finger,  if  we  attempt  it  early.  We  may  even  carry  the 
forehead  from  the  pubis  to  the  sacro-iliac  junction.  The  process 
is  still  more  simple,  when  the  occiput  is  turned  to  the  pubis,  if  we 
perform  it  early.  If,  however,  we  neglect  it,  we  find  that  in  a  few 
instances  the  head  does  not  turn  at  all,  but  enters  the  pelvis  in  the 
original  direction,  and  becomes  wedged,^  requiring  the  use  of 
instruments.  This  is  oftenest  the  case,  when  the  occiput  is  turned 
to  the  pubis ;  for  the  forehead  being  broad,  does  not,  by  a  conti- 
nuance of  labour,  slip  to  the  side  of  the  promontory  of  the  sacrum 
so  readily  as  the  occiput  would  do. 

2d,  The  side  of  the  head  may  present.  In  this  case,  the  presen- 
tation is  long  of  being  felt,  but  it  is  recognised  by  the  ear.     If,  how- 


(~rj  These  constitute  the  third  and  the  sixth  positions  of  the  vertex,  according 
to  Baudelocque.  The  comparative  infrequency  of  their  occurrency  is  illustrated 
in  the  table,  appended  to  the  chapter  on  the  Classification  of  Labours. 

(~8_)  This  by  the  French  writers  is  termed  enclavement,  and  by  the  English  im- 
paction, or  the  locked  head. 

52 


402 

ever,  it  has  been  long  pressed  in  the  pelvis,  it  is  extremely  difficult 
to  determine  the  case.  It  is  very  rare,  and  has  even  been  deemed 
to  be  impossible.  In  some  instances  the  child  has  been  turned, 
but  it  is  most  common  to  rectify  the  position  of  the  head,  by  intro- 
ducing the  hand. 

3d,  The  occiput  may  present,  the  triangular  part  of  the  bone 
being  felt  at  the  os  uteri.  It  is  known  by  its  shape,  by  the  lamb- 
doidal  suture,  and  its  vicinity  to  the  neck.  The  forehead  rests  on 
some  part  of  one  of  the  psoae  muscles,  and  from  this  oblique  posi- 
tion of  the  head,  the  labour  is  tedious.  It  has  been  proposed, 
in  this  case,  to  turn  ;  but  it  is  better,  if  we  do  any  thing,  to  rectify 
the  position  of  the  head  with  the  hand.  Nature  is,  however,  ade- 
quate to  the  delivery,  even  if  not  assisted.  Some  advise,  that  the 
woman  should,  by  a  change  of  position,  endeavour  to  remedy  the 
obliquity,  making  the  child  incline,  so  as  to  affect  the  situation  of 
the  head,  but  this  has  not  much  power  in  altering  the  position  of 
the  presentation,  at  least  after  the  water  has  been  evacuated, 

4th,  The  face  may  present  with  the  chin  to  one  of  the  acetabula, 
or  to  the  sacro-iliac  junction,  or  to  the  pubis  or  sacrum.  The  first 
two  are  the  best,  the  second  is  more  troublesome,  and  the  last  is 
worst  of  all.  When  the  face  presents,  the  labour  is  generally  tedi- 
ous and  painful,  for  it  is  little  compressible,  and  affords  a  broad 
surface,  not  well  calculated  to  take  the  proper  turns  in  the  pelvis. 
The  head,  also,  being  thrown  back  on  the  neck,  a  larger  body  must 
pass,  than  when  the  chin  is  placed  on  the  breast.  By  a  continuance 
of  the  pains,  the  face  becomes  swelled  ;  and  although  at  first  it  was 
recognisable  by  the  mouth  and  features,  yet  now  it  is  indistinct, 
and  has  been  taken  either  for  a  natural  presentation  or  the  breech. 
By  rude  treatment,  the  skin  may  be  torn ;  and  even  under  the 
best  management,  the  face,  when  born,  is  very  unseemly,  and 
sometimes  quite  black  and  elongated,  so  that  it  has  been  known  to 
measure  nearly  seven  inches.  This  is  especially  the  case  when 
the  chin  is  directed  to  the  sacrum,  and  some  children  die  from 
obstructed  circulation,  owing  to  the  continued  pressure  on  the 
jugular  veins. 

Face  presentations  have  been  attributed  sometimes  to  convulsive 
vomiting,  cough,  or  frequent  examination,  but  generally  no  evident 


403 

cause  can  be  assigned ;  and  in  the  beginning  of  labour,  the  face  it- 
self does  not  present,  but  only  the  forehead  :  hence  La  Motte  tells 
us,  that  although  at  first  he  thought  the  head  presented  properly, 
yet,  when  the  membranes  broke,  the  face  came  down. 

Some  have  advised  that  the  child  should  be  turned ;  others  that 
the  chin  should  be  raised  up,  to  make  the  upper  part  of  the  face 
come  down  ;  or  that  if  the  head  be  advanced,  a  finger  sruould  be 
inserted  into  the  mouth,  to  bring  down  the  jaw  under  the  pubis. 
Others  leave  the  whole  process  to  nature ;  but  many  endeavour 
with  the  hand  to  rectify  the  position. 

If  the  presentation  be  discovered  early,  there  can  be  little  doubt 
as  to  the  propriety  of  rectifying  the  position,  but  if  the  labour  be 
advanced,  this  is  difficult ;  and  then  it  only  remains  that  we  should 
endeavour,  if  the  labour  be  severe  and  tedious,  to  make  the  face 
descend  obliquely,  by  cautiously  but  firmly  supporting  with  a  fin- 
ger, during  the  pains,  the  chin  or  end  which  is  highest,  in  order  to 
favour  the  descent  of  the  lower  end.  When  the  chin  has  advanced 
so  far  as  to  come  near  the  arch  of  the  pubis,  we  may  follow  a  dif- 
ferent method,  and  gently  depress  it,  which  assists  the  delivery, 
for  generally  the  chin  is  first  evolved.  If,  however,  the  process  go 
on  regularly  and  tolerably  easy,  we  need  not  make  these  attempts. 
As  the  perineum  is  much  stretched,  we  must  support  it,  and  avoid 
all  hurry  in  the  exit  of  the  head. 

When  the  chin  is  directed  to  the  sacrum,  the  labour  is  sometimes 
so  tedious  as  to  require  the  application  of  instruments. 


ORDER  6.  OF  THE  UMBILICAL  CORD. 

Sometimes  the  cord  descends  before  or  along  with  the  presenting 
part  of  the  child.  This  has  no  influence  on  the  process  of  delivery, 
but  it  may  have  a  fatal  effect  on  the  child ;  for,  if  the  cord  be 
strongly  compressed,  or  compressed  for  a  length  of  time,  the  child 
shall  die,  as  certainly  as  if  respiration  were  interrupted  after  birth. 
If  the  cord  be  discovered  presenting  before  the  membranes  burst, 
or  if  the  os  uteri  be  properly  dilated  when  they  burst,  the  best 
practice  is  to  turn  the  child.    It  has  indeed  been  proposed,  to  push 


404 

the  presenting  part,  or  hook  it  upon  one  of  the  limbs  ;  but,  if  the 
hand  is  to  be  introduced  so  far,  it  is  better  at  once  to  turn  the  child. 
If  the  os  uteri  be  not  sufficiently  relaxed,  we  must  not  use  force  to 
expand  it ;  and  little  can  be  done,  except  by  rest,  to  prevent  as 
much  as  possible,  the  evacuation  of  the  water.     As  soon  as  the  os 
uteri  will  admit  the  introduction  of  the  hand,  the  child  should  be 
turned,  if  it  can  be  easily  done.     But  if  the  presentation  be  ad- 
vanced before  we  are  called,  and  turning  be  difficult,  then  we  must 
endeavour  to  keep  the  cord  slack,  or  remove  it  to  that  part  of  the 
pelvis  where  it  is  least  apt  to  be  compressed ;  or  it  will  be  still 
better,  to  endeavour  with  two  fingers  to  push  the  cord  slowly  past 
the  head,  and  prevent  it,  for  two  or  three  pains,  from  coming  down 
again. (t)     This  is  less  violent,  and  safer,  than  attempts  to  turn  in 
an  advanced  stage  of  labour.     Should  this  not  be  practicable,  and 
the  pulsation  suffer,  or  the  circulation  be  endangered,  we  must  ac- 
celerate labour  by  the  forceps.     If  the  pulsation  be  stopped,  and 
the  child  dead,  when  we  examine,  then  labour  may  be  allowed  to 
go  on,  without  paying  any  attention  to  the  cord.     The  sum  of  the 
practice  then  is,  that  when  the  os  uteri  is  not  dilated,  so  as  to  per- 
mit of  turning,  we  must  not  attempt  it ;  when  turning  is  practicable. 
it  is  to  be  performed ;  when  the  head  has  descended  into  the  pel- 
vis, the  cord  is  to  be  replaced,  or  secured  as  much  as  possible  from 
pressure ;  but  if  the  circulation  be  impeded,  the  woman  must  be 
encouraged  to  accelerate  the  labour  by  bearing  down,  or  instru- 
ments must  be  employed.  When  the  presentation  is  preternatural, 
these  directions  are  likewise  to  be  attended  to,  and  the  practice  is 
also  to  be  regulated  by  the  general  rules  applicable  to  such  labour?. 


(~tj  Mauriceau,  in  these  cases,  recommends  turning  the  funis,  and  pushing  a 
piece  of  soft  linen  after  it,  the  end  of. 'which  may  remain  hanging  without.  Dr. 
Mackenzie,  a  celebrated  accoucheur  of  London,  in  a  case  where  the  funis  pre- 
sented, pulled  down  as  much  as  he  could,  which  he  enclosed  in  a  leathern  purse  j 
and  thus  returned  it,  pushing  them  up  together  into  the  uterus  ;  in  this  case  the 
child  was  born  alive.  He  afterwards  pursued  the  same  practice,  and  sometimes 
succeeded  j  and  others  have  since  followed  his  example. 


405 


ORDER  7.  PLURALITY  OF  CHILDREN  AND  MONSTERS. 

Various  signs  have  been  mentioned,  whereby  the  presence  of  a 
plurality  of  children  in  utero  might  be  discovered,  previous  to  their 
delivery.  These  are,  an  unusual  size,  or  an  unequal  distention  of 
the  abdomen,  an  uncommon  motion  within  the  uterus,  a  very  slow 
labour,  or  a  second  discharge  of  liquor  amnii  during  parturition. 
These  signs,  however,  are  so  completely  fallacious,  that  no  reli- 
ance can  be  placed  upon  them,  nor  can  we  generally  determine  the 
existence  of  twins,  until  the  first  child  be  born.  Then,  by  placing 
the  hand  on  the  abdomen,  the  uterus  is  felt  large,*  if  it  contain 
another  child ;  and,  by  examination  per  vaginam,  the  second  set 
of  membranes  or  some  part  of  the  child,  is  found  to  present.  This 
mode  of  inquiry  is  proper  after  every  delivery. 

Soon  after  the  first  child  is  born,  pains  usually  come  on  like  those 
which  throw  off  the  placenta,  but  more  severe  ;  and  they  have  not 
the  effect  of  expelling  it,  for  it  is  generally  retained  till  after  the  de- 
livery of  the  second  child.  No  intimation  of  the  existence  of  an- 
other child  is  to  be  given  to  the  mother,  but  the  practitioner  is 
quietly  to  make  his  examination,  rupture  the  membranes,  if  they 
have  not  given  way,  and  ascertain  the  presentation.  If  it  be  such 
as  require  no  alteration,  he  is  to  allow  the  labour  to  proceed  ac- 
cording to  the  rules  of  art,  and  usually  the  expulsion  is  very  spee- 
dily accomplished.  If  the  first  child  present  the  head,  the  second 
generally  presents  the  breech  or  feet,  and  vice  versa ;  but  some- 
times the  first  presents  the  arm,  and,  in  that  case,  when  we  turn, 
we  must  be  careful  that  the  feet  of  the  same  child  be  brought  down. 
This  one  being  delivered,  the  hand  is  to  be  again  introduced,  to 
search  for  the  feet  of  the  second  child,  which  are  to  be  brought  into 
the  vagina,  but  the  delivery  is  not  to  be  hurried. 

It  sometimes  happens,  that  after  the  first  child  is  born,  the  pains 
become  suspended",  and  the  second  is  not  born  for  several  hour?. 


*  In  a  case  related  by  Mr.  Aitkin,  the  uterus  was  felt,  after  delivery,  large  and 
hard,  as  if  it  contained  another  child,  but  none  was  discovered.  In  the  course  of  a 
fortnight  the  tumour  gradually  disappeared.    Med.  Comment.  Vol.  II.  p.  "On. 


406 

\<>w  this  is  an  unpleasant  state,  both  for  the  patient  and  practition- 
er. She  must  discover  that  there  is  something  unusual  about  her; 
he  must  be  conscious  that  hemorrhage,  or  some  other  dangerous 
symptom,  may  supervene.  The  first  rule  to  be  observed  is,  that 
the  accoucheur  is  upon  no  account  to  leave  this  patient  till  she  be 
delivered.  The  second  regards  the  time  for  delivering.  Some 
have  advised  that  the  case  be  entirely  left  to  the  efforts  of  nature, 
whilst  others  recommend  a  speedy  delivery.  The  safest  practice, 
if  the  head  present,  lies  between  the  two  opinions.  If  effective 
pains  do  not  come  on  in  a  quarter  of  an  hour,  the  child  ought  to  be 
delivered  by  turning.  The  forceps  can  seldom  be  required  ;  for 
if  the  head  have  come  so  low  as  to  admit  of  their  application,  the 
delivery  most  likely  shall  be  accomplished  without  assistance.  If 
the  second  child  present  in  such  a  way,  as  that  the  feet  are  near  the 
os  uteri,  as  for  instance,  the  breech,  or  any  part  of  the  lower  ex- 
tremities, then  the  feet  are  cautiously,  but  without  delay,  to  be 
brought  down  into  the  vagina,  and  the  expulsion  afterwards  left,  if 
nothing  forbid  it,  to  nature. 

If,  however,  the  position  of  the  second  child  be  such  its  to  re- 
quire turning,  we  are  to  lose  no  time,  but  introduce  the  hand  for 
that  purpose,  before  the  liquor  amnii  be  evacuated,  or  the  uterus 
begin  to  act  strongly  on  the  child.  Turning,  in  such  circumstan- 
ces, is  generally  easy. 

In  the  event  of  hemorrhage,  convulsions,  or  other  dangerous 
symptoms,  supervening  between  the  birth  of  the  first  and  second 
child,  the  delivery  must  be  accelerated,  whatever  be  the  presenta- 
tion, and  managed  upon  general  principles. 

When  there  are  more  children  than  two,  the  woman  seldom 
goes  to  the  full  time,  and  the  children  survive  only  a  short  time. 
There  is  nothing  peculiar  in  the  managament  of  such  labours. 

It  still  remains  to  observe,  that  we  ought  to  be  peculiarly  care- 
ful in  conducting  the  expulsion  of  the  placentae  of  twins.  Owing 
to  the  distention  of  the  uterus,  and  its  continued  action  in  expelling 
two  children,  there  is  a  greater  than  usual  risk  of  uterine  hemor- 
rhage taking  place.  The  patient  must  be  kept  very  quiet  and 
cool,  moderate  pressure  should  be  made  with  the  hand  externally 
on  the  womb,  or  gentle  friction  may  be  employed,  and  no  forcible 


407 

attempts  are  to  be  permitted,  for  the  extraction  of  the  placentae, 
by  pulling  the  cords.  If  hemorrhage  come  on,  then,  the  hand  is 
to  be  introduced  to  excite  the  uterine  action,  and  the  two  placentas 
are  to  be  extracted  together.  The  application  of  the  bandage, 
and  other  subsequent  arrangements,  must  be  conducted  with  cau- 
tion, lest  hemorrhage  be  excited. 

The  placentas  are  often  connected,  and  therefore  they  are 
naturally  expelled  together,  but  this  adds  nothing  to  the  difficulty 
of  the  process.  Sometimes  they  are  separate,  and  the  one  is 
thrown  off  before  the  other ;  or  it  may  even  happen,  that  the  pla- 
centa of  the  first  child  is  expelled  before  the  second  child  be  born, 
but  this  is  very  rare,  and  is  not  desirable. 

Women,  who  have  borne  a  plurality  of  children,  are  more  dis- 
posed than  others  to  puerperal  diseases,  and  must  therefore  be 
carefully  watched.  It  rarely  happens,  that  they  are  able  to  nurse 
both  children  without  injury. 

It  is  possible  for  two  children  to  adhere,  or  for  one  child  to  have 
some  additional  organ  belonging  to  a  second,  as,  for  example,  an 
arm  or  a  head.  Such  cases  of  monstrosity  may  produce  consider- 
able difficulty  in  the  delivery ;  and  the  general  principle  of  con- 
duct must  be,  that  when  the  impediment  is  very  great,  and  does 
not  yield  to  such  force  as  can  be  safely  exerted,  by  pulling  that 
part  which  is  protruded,  a  separation  must  be  made,  generally  of 
that  part  which  is  protruded,  and  the  child  afterwards  turned,  if 
necessary.  Unless  the  pelvis  be  greatly  deformed,  it  will  be  prac- 
ticable to  deliver,  even  a  double  child,  by  means  of  perforation  of 
the  cavities,  or  such  separation  as  may  be  expedient,  and  the  use 
of  the  hand,  forceps,  or  crotchets,  according  to  circumstances.  A 
great  degree  of  deformity  may  render  the  caesarean  operation  ne- 
cessary. 

With  respect  to  children  who  are  monstrous  from  deficiency  of 
parts,  I  may  take  the  present  opportunity  of  observing,  that  no 
difficulty  can  arise,  during  the  delivery,  except  in  ascertaining  the 
presentation,  if  the  malformation  be  to  a  great  extent,  as,  for  in- 
stance, in  acephalous  children. 


408 


CHAP.  V. 

Of  Tedious  Labour. 
ORDER  1.  FROM  IMPERFECTION  OF  MUSCULAR  ACTION. 

If  the  expulsive  force  of  the  uterus  be  diminished,  or  the  re- 
sistance to  the  passage  of  the  child  be  increased,  the  labour  must 
be  protracted  beyond  the  usual  time,  or  a  more  than  ordinary  de- 
gree of  pain  must  be  endured. 

Tedious  labour  may  occur  under  three  different  circumstances : 

First,  The  pains  may  be  from  the  beginning  weak  or  few,  and 
the  labour  may  be  long  of  becoming  brisk. 

Second,  The  pains  during  the  first  stage,  may  be  sharp  and  fre- 
quent, but  not  effective ;  in  consequence  of  which  the  power  of 
the  uterus  is  worn  out  before  the  head  of  the  child  have  fully  en- 
tered into  the  pubis,  or  come  into  a  situation  to  be  expelled. 

Third,  The  pains,  during  the  whole  course,  may  be  strong  and 
brisk,  but  from  some  mechanical  obstacle,  the  delivery  may  be 
long  prevented,  and  it  may  even  be  necessary  to  have  recourse  to 
artificial  force. 

It  is  farther  necessary  for  me  to  premise,  that  the  same  patient, 
in  different  labours,  shall  be  delivered  with  varying  celerity  and 
case,  although  the  size  of  the  children  be  the  same.  The  protrac- 
tion, therefore,  cannot  depend  on  purely  mechanical  causes,  but  is 
rather  to  be  attributed  to  resistance  afforded  by  the  soft  parts,  as 
living  organs,  and  the  state  of  action  of  the  uterine  fibres.  The  de- 
livery of  the  child  depends  on  contraction  of  the  uterus,  and  relax- 
ation of  its  orifice,  and  that  of  the  vagina,  and  muscles  connected 
with  the  perineum ;  and  these  two  processes  are  not  only  influ- 
enced by,  but  are  also  generally  proportionate  to  each  other.  Easy 
and  speedy  relaxation  is  productive  of  rapid  and  great  contraction, 
which  is  not  to  be  measured  or  determined  by  the  degree  of  pain 
or  sensation,  but  of  efficiency.  Powerful  contraction  of  the  uterus, 
is  attended  with  proportionally  rapid  relaxation  of  the  opposing 


409 

soft  parts,  or  at  least  of  the  os  uteri ;  and  if  the  latter  state  do  not 
take  \>laee,  the  former  cannot  easily  exist.  When  mechanical  as- 
sistance does  stimulate  to  more  frequent  and  violent  action,  it  is 
often  more  in  appearance  than  reality,  at  least  so  far  as  the  uterus 
is  concerned.  The  sensation  may  be  greater,  but  the  actual  effort 
made  by  the  uterus,  is  not  always  so  great  as  the  sensation  would 
imply.  The  abdominal  muscles  act  more  powerfully,  and  doubtless 
the  uterus  itself  is  at  last  roused  or  excited  to  strong  action,  when 
the  resistance  is  continued,  as  for  instance,  by  a  contracted  pelvis, 
or  bad  position  of  the  child.  The  patient  says,  she  feels  as  if  she 
would  burst ;  and  in  some  cases  the  uterus  is  actually  ruptured,  but 
in  many  more  inflammation  is  excited  by  the  efforts.  Nevertheless, 
even  in  this  kind  of  resistance,  which  docs  not  depend  on  the  os 
uteri,  it  is  usual  for  the  action  of  the  uterus  at  first  to  be  impeded ; 
the  primary  stage  of  labour  is  slow,  and  the  pains  inefficient.  But 
this  is  more  remarkably  the  case,  when  the  resistance  is  seated  in 
the  os  uteri ;  for  then,  although  the  pains  may  be  frequent,  they 
are  long  of  becoming  powerful.  Then  the  abdominal  muscles 
co-operate  strongly  and  press  down  the  uterus,  along  with  the  head, 
into  the  pelvis.  This  is  particularly  illustrated  by  cases  of  morbid 
contraction,  or  obliteration  of  the  os  uteri. 

Various  causes  may  protract  labout ;  and  although  I  have  thought 
it  right  to  divide  tedious  labour  into  two  orders ;  yet,  in  point  of 
fact,  the  causes  sometimes  operate  in  such  a  way,  as  to  make  the 
case  a  mixed  one,  referable  partly  to  both  divisions.  They  may 
be  arranged  under  the  following  heads :  First,  feeble  or  sluggish 
and  languid  action  of  the  uterus.  Second,  partial  or  spasmodic  ac- 
tion of  the  uterus.  Third,  restrained  action,  the  energy  of  the  uterus 
being  prevented  from  being  put  forth  by  some  other  cause.  Fourth, 
an  unusual  obstacle  to  the  issue  of  the  child.  These  states  or 
causes,  may  be  excited  by  circumstances  in  many  respects  differing 
from  one  another,  and  which,  at  first  view,  we  would  not  suppose 
to  act  on  one  principle.  The  most  important  of  these,  we  must 
presently  consider  separately.  When  again  we  come  to  view  the 
means  which  we  possess  of  counteracting  their  causes,  and  accele- 
rating labour,  in  order  that  we  may  choose  the  one  best  adapted 
to  the  case,  we  find  that  they  may  be  referred  to  the  following : 

53 


410 

First,  diminishing  resistance,  or  promoting  relaxation,  which  in- 
creases contraction.  Under  this  head  may  be  included  blood- 
letting, gently  dilating  the  os  uteri,  rupturing  the  membranes,  im- 
proving the  position  of  the  presentation.  Second,  exciting  the  ac- 
tion of  the  uterus  by  stimulating  its  fibres,  directly  or  by  sympathy. 
Under  this  head  may  be  included,  the  effect  of  cordials  prudently 
given,  heat,  friction,  gentle  exercise,  clysters,  spontaneous  vomit- 
ing.fwj  Third,  suspending  weak  and  useless,  or  wearing-out,  action, 
by  a  suitable  anodyne,  in  order  that  the  energy  of  the  womb  and 
of  the  system  may  recruit  by  rest.  Fourth,  removing  partial  or 
spasmodic  action  by  a  full  dose  of  opium.  Fifth,  allaying  general 
irritation  of  the  system,  which  is  interfering  with  the  individual  ac- 
tion of  the  uterus,  by  a  small  or  moderate  dose  of  laudanum,  and 
thus  concentrating  the  action  in  the  uterus ;  or  premising  venesec- 
tion, if  the  state  of  the  vascular  system  indicate  this.  Sixth,  re- 
moving undue  action  from  other  parts,  which  are  acting  in  place  of 
the  uterus,  and  checking  or  subducting  its  action,  on  the  principle 
of  the  sympathy  of  equilibrium,  which  I  have  alluded  to  in  page 
340,  and  more  fully  explained  in  another  work.  Seventh,  if  none 
of  these  are  applicable  or  effectual,  then  it  only  remains  to  employ 
artificial  or  instrumental  aid. 

Having  made  these  general  remarks,  I  now  proceed  to  consider 

(uj  In  cases  where  the  contractions  of  the  uterus  are  inefficient  from  want 
of  energy  or  irregular  action  of  the  uterine  fibre,  provided  the  cervix  and  os  ute- 
ri, as  well  as  the  external  parts  are  sufficiently  dilated  or  disposed  to  dilate ;  re- 
course may  be  advantageously  had  to  the  ergot,  or  spurred  rye.  Under  these 
circumstances  the  editor  has  frequently  derived  the  most  decided  advantage 
from  its  use,  given  in  fine  powder,  in  the  dose  of  about  one  scruple  in  syrup,  and 
has  seldom  had  occasion  to  repeat  it.  In  about  twenty  minutes  after  the  exhibi- 
tion of  the  article,  the  contractions  of  the  uterus  are  invigorated,  and  the  process 
accelerated  in  some  instances  probably  several  hours. 

In  judicious  and  discriminating  exhibition,  this  article  of  the  materia  medica 
may  be  considered  as  a  valuable  acquisition  in  the  practice  of  midwifery ;  al- 
though, like  all  other  powerful  medicines,  in  rash  and  inexperienced  hands  may 
possibly  do  harm. 

For  fuller  information  on  this  subject  the  reader  is  referred  to  the  papers  of 
Drs.  Stearns,  Prescott,  andBigelow. 

The  credit  of  introducing  this  medicine  into  obstetrical  practice  generally,  is 
exclusively  due  to  the  practitioners  of  the  United  States. 


411 

particular  states.  The  first  to  be  noticed  is,  that  dependent  on  a 
weak  or  inefficient  action  of  the  uterine  fibres.  This  may  be  occa- 
sioned by  general  debility  or  inactivity,  but  more  frequently  it  pro- 
ceeds from  the  state  of  the  uterus  itself.  It  is  marked  by  feeble 
pains,  which  dilate  the  os  uteri  slowly,  and  are  long  of  forcing 
down  the  head.  But  although  the  pains  be  feeble,  they  may  pro- 
duce as  great  sensation  as  usual,  for  this  is  proportioned  rather  to 
the  sensibility  than  to  the  vigour  of  the  part.  It  is,  however,  usual, 
when  labour  is  protracted  from  thiscause,  for  the  pains  to  be  less 
severe  than  in  natural  labour.  They  may  come  much  seldomer, 
or,  if  frequent,  they  may  last  much  shorter,  and  be  less  acute.  The 
whole  process  of  labour  is  sometimes  equally  tedious,  but,  in  most 
cases,  the  delay  principally  takes  place  in  one  of  the  stages,  gene- 
rally in  the  first,  if  the  cause  exist  chiefly  in  the  uterus.  If,  how- 
ever, it  proceed  from  general  debility,  we  often  find,  that  if  the  first 
stage  be  tedious,  the  powers  are  thereby  so  exhausted,  that  the  se- 
cond can  with  difficulty  be  accomplished.  Hence,  although  con- 
sumptive patients  often  have  a  rapid  delivery,  yet  if  the  first  stage 
be  slow,  the  head  frequently  cannot  be  expelled  without  assistance. 
It  is  not  always  easy  to  say  what  the  cause  of  this  slow  action  of 
the  uterus  is.  Sometimes  it  proceeds  from  contraction  commenc- 
ing rather  prematurely ;  or  from  the  membranes  breaking  very 
early,  and  the  water  oozing  slowly  away ;  or  from  some  other  organ 
becoming  too  active ;  or  from  the  uterus  being  greatly  distended 
by  liquor  amnii,  or  a  plurality  of  children ;  or  from  fear,  or  other 
passions  of  the  mind  operating  on  the  uterus ;  or  from  torpor  of 
the  uterine  fibres,  frequently  combined  with  a  dull  leucophlegmatic 
habit,  or  with  a  constitution  disposed  to  obesity ;  or  from  general 
weakness  of  the  system. 

In  a  state  of  suffering  and  anxiety,  the  mind"  is  apt  to  exaggerate 
every  evil,  to  foresee  imaginary  dangers,  to  become  peevish  or  de- 
sponding, and  to  press  with  injudicious  impatience  for  assistance, 
which  cannot  safely  be  granted.  Great  forbearance,  care,  and  judg- 
ment, then,  are  required  on  the  part  of  the  practitioner;  who, 
whilst  he  treats  his  patient  with  that  gentleness  and  compassionate 
encouragement,  which  humanity  and  refinement  of  manners  will 
dictate,  is  steadily  to  do  his  duty,  being  neither  swayed  by  her 


412 

fears  and  entreaties,  nor  by  a  selfish  regard  to  the  saving  of  his  own 
time. 

Some  women  seem  constitutionally  to  have  a  lingering  labour, 
being  always  slow.  In  such  cases,  unless  the  process  be  consider- 
ably protracted,  or  attended  with  circumstances  requiring  our  inter- 
ference, it  is  neither  useful  nor  proper  to  do  more  than  encourage 
the  patient,  and  preserve  her  strength. 

A  variety  of  means  were  at  one  time  employed  for  exciting  the 
action  of  the  uterus,  such  as  forcible  dilatation  of  the  os  uteri,  and 
the  use  of  emetics,  purgatives,  or  stimulants.  Avery  different  prac- 
tice now  happily  obtains ;  the  patient  is  kept  cool,  tranquil,  and 
permitted  to  repose;  the  mildest  drink  is  allowed ;  all  fatiguing 
efforts  are  prohibited;  and  she  is  encouraged  by  the  mental  stimuli 
of  cheerfulness  and  hope,  rather  than  by  wine  and  cordials.  But, 
whilst  in  cases  where  labour  is  only  a  little  protracted,  and  the 
cause  not  very  well  marked,  we  trust  entirely  to  this  treatment, 
with  the  addition  of  a  saline  clyster,  which  is  of  much  service,  and 
ought  seldom  to  be  omitted,  yet,  where  it  is  longer  delayed,  some 
other  means  are  allowable,  and  may  be  necessary. 

The  pains  in  tedious  labour,  connected  with  defective  uterine 
action,  may  be  continuing  regular,  but  weak,  not  from  exhaustion, 
but  rather  from  the  uterus  not  exerting  the  power  it  has ;  or  there 
may  be  a  tendency  to  remit,  the  pains  coming  on  seldom.  In  the 
first  of  these  states,  we  have  to  consider  whether  there  be  heat  of 
the  skin,  full  pulse,  with  thirst  and  restlessness.  If  so,  and  especi- 
ally if  the  os  uteri  be  not  relaxed,  venesection  will  be  of  great  bene- 
fit, by  making  the  uterus  act  with  more  freedom,  and  its  mouth 
yield  with  great  readiness^  We  know  that  in  most  eases  of  uterine 
hemorrhage,  the  os  uteri,  even  where  there  is  no  effective  labour, 
and  scarcely  any  pain,  is  not  merely  dilatable,  but  is  partially  di- 
lated. In  this  instance,  however,  the  benefit  of  evacuation  cannot 
be  derived,  for  the  discharge  injures  and  impairs  the  whole  power 
of  the  uterus,  and  in  proportion  as  the  os  uteri  is  extended,  the 
quantity  of  the  blood  which  flows  is  increased  ;  besides,  the  evacua- 
tion usually  begins  before  labour  commences,  and  pains  do  not 
come  on  till  the  loss  of  blood  excite  them.  We  learn,  however, 
from  this  example,  the  influence  of  hemorrhage  in  relaxing  the  os 


413 

uteri,  and  if  we  can  do  this  without  impairing  the  power  of  the 
womb,  we  have  certainly  a  powerful  mean  of  accelerating  labour ; 
venesection  does  this  in  certain  cases.  It  can  do  no  good,  but 
much  harm,  in  cases  of  exhaustion,  or  in  cases  where  the  resist- 
ance is  afforded  by  a  contracted  pelvis,  and  all  other  circumstances 
are  right.  But  in  cases  where  the  parts,  through  which  the  child 
must  pass  are  rigid  or  dry,  or  hot  and  tender,  or  where  the  pains 
are  great,  but  irregular  and  inefficient,  or  the  membranes  have 
given  way  prematurely,  the  pains  sharp,  but  abortive,  and  the  os 
uteri  thick  or  hard,  or  the  patient  is  feverish,  blood-letting  is  safe, 
and  may  be  expected  to  do  good.  That  it  is  safe,  we  know  from 
the  experience  of  former  ages  and  other  countries,  as  well  as  from 
our  own  observation  in  cases  of  convulsions,  where  a  great  quan- 
tity of  blood  is  taken  away  with  present  advantage  and  future  im- 
punity. It  is,  however,  a  remedy,  which  if  imprudently  employed, 
may  do  much  mischief.  In  cases  of  exhaustion,  for  instance,  it 
must  be  dangerous ;  and  in  every  constitution,  and  under  every 
circumstance  in  which  it  would,  independent  of  labour,  be  im- 
proper to  evacuate,  it  is  evident  that  it  will  be  hurtful,  unless  we 
Can  thereby  save  the  patient  prolonged  exertion  and  exhaustion. 
In  natural  labour,  it  is  neither  necessary  nor  proper ;  in  labour  not 
greatly  protracted,  nor  unusually  severe  and  slow  in  its  steps,  it  is 
not  to  be  resorted  to.  It  is  better  to  trust,  in  these  cases,  to  the 
use  of  clysters,  to  gentle  motion  and  change  of  posture,  or  to  sleep, 
if  it  offer  naturally,  and  the  patient  require  to  be  recruited. 

The  effect  of  venesection  in  shortening  the  process  of  labour, 
and  in  rendering  the  pains  in  many  cases  brisker,  is  to  be  explained 
by  its  power  in  relaxing  the  parts,  and  diminishing  the  resistance 
afforded.  It  is  a  fact  not  sufficiently  attended  to,  that  in  many 
cases  a  very  moderate  resistance,  which  we  should  think  the  ute- 
rus might  easily  overcome,  does  retard  the  expulsive  process,  and 
render  the  pains  irregular  or  inefficient.  Thus,  I  know  from  ex- 
perience, that  the  membranes  may  be  so  tough  as  not  readily  to 
give  way,  and  in  this  case  the  pains  do  become  less  effective,  and 
the  labour  is  protracted  till  they  are  opened.  Whenever  the  re- 
sistance is  removed,  the  pains  become  brisk  and  forcing.     In  the 


414 

same  way,  relaxing  the  os  uteri  by  blood-letting,  excites  the  ute- 
rine fibres  to  brisker  action. 

If  the  woman  be  fatigued  or  debilitated,  and  the  pulse  weaker 
(ban  in  lingering  labour,  we  shall  derive  advantage  from  the  use 
of  a  smart  clyster,  followed  by  thirty  drops  of  laudanum,  or  a  pro- 
portional quantity  in  an  injection.  This  does  not  suspend  the 
pains,  but  rather  excites  them.  A  similar  stimulus  is  sometimes 
given  by  a  gentle  purge,  but  this  is  more  slow  and  uncertain  in  its 
effects. 

When  there  is  a  strong  tendency  in  the  pains  to  remit,  or  keep 
off,  we  are  to  follow  pretty  nearly  the  same  conduct  widi  regard 
to  venesection,  in  the  circumstances  which  I  have  pointed  out,  as 
admitting  of  it;  but  it  is  much  more  rarely  required  in  those 
cases,  than  where  the  pains  are  less  frequent.  When  it  is  em- 
ployed, it  either  procures  a  remission  and  sleep,  followed  by  brisk 
action,  or  it  excites  more  immediately  the  pains ;  for  whatever 
diminishes  the  resistance  or  obstacle,  whatever  produces  relaxa- 
tion, speedily  acts  as  a  stimulus  to  the  uterus  to  contract :  cordials 
and  stimulants  are  more  doubtful  in  their  effect.  If,  however, 
blood-letting  be  improper,  we  give  a  clyster,  and  then  forty  drops 
of  laudanum,  which  either  makes  the  pains  effective  and  brisk,  or 
suspends  them  for  a  time,  till  the  womb  recruit. 

There  is  another  state  in  which  the  pains  are  weak,  or  remiss, 
or  are  ineffective  from  absolute  exhaustion  or  debility ;  and  we 
distinguish  this  case  by  the  weak  pulse,  languor,'  and  previous 
fatigue,  and  in  part  by  the  constitution  of  the  woman.  This  is  the 
only  case  in  which  cordials  are  proper,  and  they  must  even  here 
be  given  prudently,  lest  they  produce  "a  febrile  state.  It  is  also 
useful  to  suspend  for  a  time  the  uterine  action,  and  procure  rest 
by  an  anodyne  clyster.  We  must  take  care  that  we  do  not  delay 
delivery  too  long,  or  trust  too  much  to  nature. 

Premature  rupture  of  the  membranes,  is  apt  to  occasion  spasmo- 
dic action  of  the  uterus,  or  irregular  and  inefficient  pains;  besides, 
a  little  water  passes  between  the  head  of  the  child  and  the  os  uteri 
during  every  pain,  and  the  effect  is  rather  to  press  out  gradually 
the  water,  than  to  open  the  os  uteri,  which  is  seldom  effectually 


415 

acted  on,  till  the  whole,  or  almost  the  whole  water,  has  been 
evacuated,  so  as  to  allow  the  head  to  be  pressed  on  the  orifice,  and 
the  uterine  fibres  to  act  on  that  orifice  over  the  presenting  part.  In 
a  natural  state,  the  bag  remains  entire,  until  the  os  uteri  have  been 
considerably  opened,  and  every  pain  gently  dilates  it,  both  by  the 
uterus  acting  on  the  orifice,  and  also  by  the  membranes  when 
pushed  out,  doing  naturally,  what  is  effected  in  some  cases  artifi- 
cially by  the  finger,  that  is,  mechanically  dilating  the  mouth.  The 
pressure  of  the  membranes  also  excites  active  pains.     When  the 
presentation  is  preternatural,  the  os  uteri  is  longer  of  opening  than 
when   the   head   presents;    the   membranes  do  not  protrude   so 
broadly,  nor  does  the  presentation  act  so  well  on  the  os  uteri,  or 
excite  it  so  effectually.     Whilst  rupture  of  the  membranes,  then, 
may  in  some  cases  prove  a  useful  stimulus,  in  others,  when  it  is 
without  judgment  or  necessity  resorted  to,  it  must  be  prejudicial. 
If  the  water  be  discharged  very  early  in  labour,  or  before  the  pains 
come  on,  the  process  is  often  lingering,  but  is  not  always  so.  The 
os  uteri  is,  when  we  fhst  examine,  projecting,  then  it  becomes  flat, 
but  the  lips  thick ;  then  they  become  thinner  and  more  dilated, 
and  presently  very  thin  ;  and  the  lower  part  of  the  uterus  is  per- 
haps applied  so  closely  to  the  head,  that  at  first  it  might  be  taken 
for  the  head  itself.     In  favourable  cases  these  changes  may  take 
place  quickly,  but  they  may  also  be  very  slow,  and  the  labour 
tedious,  the  pains  sharp  and  ineffective,  and  the  water  discharged 
in  small  quantity  with  each  pain.     The  pains  are  severe,  but  pro- 
duce very  little  effect,  and  often  when  they  go  off,  are  succeeded 
by  a  most  distressing  uneasiness  in  the  back,  lasting  for  nearly  a 
minute  after  the  pain  ;  indicating  in  general  the  existence  of  spas- 
modic action.     A  saline  clyster  is  of  much  benefit  in  this  kind  of 
labour  ;  and  it  is  useful  to  press  up  the  head,  especially  during  the 
pains,  to  favour  the  evacuation  of  the  water  ;  for,  whenever  this  is 
accomplished,  naturally  or  artificially,  the  action  becomes  much 
stronger.     It  is  also  useful  to  detract  blood,  if  the  os  uteri  be  rigid, 
the  parts  not  disposed  to  yield,  and  the  pains  very  severe.     It  is 
peculiarly  proper  when  the  woman  has  rigours.     When  the  organs 
are  firm,  and   the  pains  are  lingering,  it  causes  relaxation,  and 
quickens  the  pains.     If,  on  the  other  hand,  the  os  uteri  be  lax  and 


416 

thin,  or  soft,  it  is  both  safe  and  advantageous  to  dilate  it  gently 
with  the  finger  during  a  pain.  If  this  be  done  cautiously,  it  gives 
no  additional  uneasiness,  whilst  the  stimulus  seems  to  direct  the 
action  of  the  uterine  fibres  more  efficiently  towards  the  os  uteri, 
which  sometimes  thus  clears  the  head  of  the  child  very  quickly, 
and  the  pains  which  formerly  were  severe,  but,  in  the  language  of 
the  patient,  unnatural,  and  doing  no  good,  become  effective  and 
less  severe,  though  more  useful.  This  advice,  however,  is  not 
meant  to  sanction  rash  and  unnecessary  attempts  to  dilate  the  os 
uteri,  which  sometimes  render  labour  more  tedious  by  interrupt- 
ing the  natural  process,  and  also  lay  the  foundation  for  inflamma- 
tory affections  afterwards.  When  the  pains  are  irregular,  and  are 
succeeded  by  aching  of  the  back,  if  the  state  of  the  os  uteri  do  not 
indicate  venesection,  a  full  dose  of  laudanum,  not  less  than  forty 
drops,  may  be  given  with  advantage. 

In  the  case  I  have  just  considered,  I  have  spoken  of  the  effects 
of  dilating  the  os  uteri,  but  I  do  not  mean  to  say,  that  the  practice 
is  useful  in  such  a  case  alone  ;  for,  in  most  cases  of  tedious  labour, 
it  is  beneficial,  and,  as  the  subject  is  important,  I  shall  explain  my 
sentiments  on  it  fully.  Forcible  and  irritating  dilatation  of  the  os 
uteri,  even  when  it  is  not  productive  of  dangerous  consequences, 
is  apt  to  occasion  irregular  or  spasmodic  action  of  the  uterus. 
Two  circumstances  are  necessary  to  render  it  safe  :  the  os  uteri 
must  be  lax  and  dilatable,  and  the  dilatation  must  be  gradually  and 
gently  effected  during  the  continuance  of  a  natural  pain.  If 
attempted  in  the  absence  of  pain,  and  especially  if  attempted  so  as 
to  give  pain,  it  is  apt  to  excite  partial  or  spasmodic  action,  and, 
under  any  circumstance,  violent  or  forcible  dilatation,  besides 
injuring  the  uterine  action  may  lay  the  foundation  of  future  disease. 
It  is  done  best  by  pressing  on  the  anterior  edge  of  the  os  uteri, 
during  a  pain,  with  two  fingers,  with  such  moderate  force  as  shall 
not  give  additional  pain,  and  shall  appear  to  excite  the  natural  dila- 
tation as  much  as  to  produce  mechanical  opening.  By  doing  this 
for  several  pains  in  succession,  or  occasionally  during  a  pain,  at 
intervals,  according  to  the  effect  produced  and  the  disposition  to 
yield,  we  shall  soon  have  the  os  uteri  completely  dilated.  This  is 
an  old  principle,  but  it  was  rashly  practised,  and  too  universalis 


417 

adopted,  which  made  it  meet  with  just  reprobation,  and  some, 
knowing  this,  may  be  surprised  at  meeting  with  such  an  advice  in 
modern  times.  Let  not  the  principle  suffer  from  its  abuse,  else 
where  is  the  plan  which  could  stand  its  ground  ?  It  is  perfectly 
clear,  that  when  the  process  is  going  on  well,  interference  is  im- 
proper, but  it  is  no  less  evident,  that  if  a  long  time  is  to  be  spent 
in  accomplishing  the  first  stage  of  labour,  or  dilatation  of  the  os 
uteri,  the  vigour  of  the  uterus  and  strength  of  the  patient  may  be 
impaired  so  much  as  to  render  the  subsequent  stage  dangerously 
tedious,  or  to  prevent  its  completion,  at  least  consistently  with  safe- 
ty ;  the  first  stage  of  labour  ought  always  to  be  accomplished 
within  a  certain  time,  varying  somewhat  according  to  the  constitu- 
tion of  the  patient  and  the  degree  of  pain.  It  is  an  undeniable 
proposition,  that  there  is  in  every  case  a  period  beyond  which  it 
cannot  be  protracted  without  exhaustion  ;  and  it  is  no  less  certain, 
that  if  we  wish  to  avoid  this  exhaustion,  which  may  be  followed  by 
pernicious  effects,  we  have  only  the  choice  of  either  suspending 
the  action  altogether  for  a  time,  or  of  endeavouring  to  render  it 
more  efficient,  and  of  effecting  the  desired  object  within  a  safe  pe- 
riod. The  first  is  sometimes  adopted,  but  is  not  always  practi- 
cable, nor  is  it  always  prudent  to  counteract  uterine  action  by 
strong  opiates.  The  second  is  safer,  and  one  of  the  means  of 
doing  so  is  that  under  consideration.  If  the  pain  be  continuing1 
without  suspension,  or  an  interval  of  some  hours,  and  the  labour 
be  going  on  all  the  time,  but  slowly,  it  is  a  good  general  rule  to 
effect  the  dilatation  of  the  os  uteri  within  ten  or  twelve  hours,  at 
the  farthest,  from  the  commencement  of  regular  labour.  This  is 
done,  if  the  os  uteri  be  flat  and  applied  to  the  head,  by  the  method 
above  described.  If  it  be  somewhat  projected,  it  is  aided  by  in- 
troducing two  fingers,  and  extending  them  laterally  with  gentle- 
ness, during  a  pain.  The  dilatation  is  easily  and  safely  effected, 
if  the  case  be  proper  for  it ;  if  not,  bleeding  or  an  opiate,  if  the 
former  be  not  indicated,  will  soon  bring  about  a  favourable  state. 
Of  the  benefit  and  perfect  safety  of  this  practice  I  can  speak  posi- 
tively, and  am  happy  to  strengthen  my  position  by  the  authority  of 
Dr.  Hamilton,  who  makes  it  a  rule  to  have  the  first  stage  of  labour 
finished  within  a  given  time.     I  need  scarcely,  however.  a.cU\  thai. 

54 


iii  enforcing  this  rule  of  conduct,  it  should  be  recollected  that,  to 
render  it  proper,  the  pains  must  be  continuing  so  often  and  so 
decidedly,  that  the  patient  can  be  said  to  be  in  actual  labour  all  the 
time.  There  are  many  cases  where  pains,  at  first  regular,  have 
gone  off  for  many  hours,  or  where  they  have  come  occasionally  in 
a  dull  slight  way,  for  a  couple  of  days,  but  they  have  given  little 
inconvenience,  have  scarcely  interrupted  sleep,  and  had  little 
effect  on  the  os  uteri.  They  are  more  of  the  nature  of  false  pains  : 
the  patient  can  hardly  be  said  to  be  in  labour,  and  is  in  no  respect 
fatigued.  If  interference  be  proper  in  such  cases,  it  is  by  other 
means,  by  opiates,  by  enemata,  or  remedies  and  applications  evi- 
dently pointed  out  by  the  nature  of  the  pains  which  have  formerly 
been  considered. 

If,  again,  in  lingering  labour,  the  membranes  be  entire,  the  os 
uteri  soft,  lax,  and  considerably  dilated,  and  the  presentation  na- 
tural, it  is  allowable  and  beneficial  to  rupture  the  membranes; 
and  this  is  more  especially  proper,  if  the  uterus  be  unusually  dis- 
tended. The  evacuation  of  the  water  is  succeeded  by  more  pow- 
erful action,  a  circumstance  which,  whilst  it  points  out  the  advan- 
tage of  the  practice  in  the  case  under  consideration,  forbids  its  em- 
ployment in  natural  labour,  where  the  process  is  going  on  with  a 
regularity  and  expedition,  consistent  with  the  views  of  nature,  and 
the  safety  of  the  woman. 

I  have  also  already  pointed  out  the  injurious  effects  which  fre- 
quently follow  premature  evacuation  of  the  water  ;  but  under  the 
circumstances  at  present  enumerated,  the  rupture  of  the  membranes 
is  beneficial.  Taking  away,  at  a  favourable  time,  the  resistance 
afforded,  tends  to  excite  efficiently  the  action  of  the  uterus,  and 
promotes  labour.  If  the  os  uteri  be  lax,  and  especially  if  its  edges 
be  thin  and  soft,  and  the  orifice  considerably  dilated,  the  same  ef- 
fects may  be  produced  on  it  by  this  practice,  that  would  be  in 
cases  of  greater  rigidity  by  venesection  ;  for  both  excite  labour  by 
diminishing  resistance.  The  more  that  the  os  uteri  is  dilated  be- 
yond the  size  of  half-a-crown,  the  more  beneficial,  ceteris  paribus, 
will  the  practice  be  :  on  the  other  hand,  when  the  os  uteri  is  firm 
and  little  dilated,  and  the  other  soft  parts  rigid,  this  practice,  so 
far  from  being  useful,  is  hujtful  and  dangerous. 


419 

An  erect  posture  is  another  mean  which  operates  in  part  on  the 
■same  principle,  for  it  calls  in  the  aid  of  gravity,  adding  the  pressure 
of  the  child  to  the  action  of  the  uterus.  The  water  is  allowed  to 
run  freely  out,  and  the  continued  application  of  the  presentation  to 
the  dilating  os  uteri,  excites  action.  The  child  must  be  more  ea- 
sily propelled,  surely,  if  it  be  in  such  a  situation  as  to  allow  it  to 
fall  out  by  its  own  weight,  were  it  not  prevented  by  the  soft  parts, 
than  if  it  rested  on  a  horizontal  surface  and  required  to  be  moved 
along  that,  by  muscular  effort,  as  is  the  case  in  a  recumbent  pos.- 
ture.  The  difference  of  facility,  then,  becomes  truly  a  stimulus. 
Besides,  the  muscular  motion,  or  walking,  which  is  employed  in 
an  erect  position,  does  good,  either  by  exciting  the  womb  directly, 
or  by  removing  sympathetic  pains  in  the  muscles. 

Sometimes,  after  the  first  stage  is  advanced,  and  the  os  utatt  is 
nearly  dilated,  the  second  does  not  commence  for  some  hours  ; 
but  the  first  kind  of  pains  continue  in  different  degrees  of  severity 
without  producing  any  perceptible  effect.  If  no  particular  cause 
require  our  interference,  it  is  best  to  trust  to  time  ;  but,  if  there 
be  no  change  soon,  labour  may  be  accelerated  by  rupturing  the 
membranes,  or,  if  they  have  already  broken,  we  may  place  two 
fingers  on  the  margin  of  the  os  uteri,  which  is  next  the  pubis,  and 
gently  assist  it,  during  the  pains,  to  slip  over  the  head. 

When  a  woman  is  greatly  reduced  in  strength,  previous  to  la- 
bour, that  process  is  looked  forward  to  with  apprehension.  It  is, 
however,  often  very  easy.  But,  if  it  should  be  protracted,  the 
patient  is  to  be  kept  from  every  exertion.  The  general  plan  of 
treatment  pointed  out  for  such  cases  is  to  be  followed,  and,  if  the 
strength  fail,  the  child  must  be  delivered.  We  must  be  particular- 
ly careful  that  hemorrhage  do  not  take  place  after  delivery,  or  that 
it  be  promptly  stopped. 

If  the  head  rest  long  on  the  perineum  in  tedious  labour,  the 
pains  having  little  effect  in  protruding  it,  especially  if  the  first  stage 
have  been  lingering,  it  comes  to  be  a  question,  whether  we  shall 
deliver  the  woman.  This  case  is  different  from  that  where  the 
difficulty  proceeds  from  a  contracted  pelvis,  for  the  head  is  low 
down,  the  bones  are  not  squeezed  nor  misshapen,  there  is  only  a 
swelling  of  the  scalp,  the  finger  can  be  passed  round  the  head,  and 


420 

fwo  or  three  strong  pains  might  expel  it.  The  propriety  of  em- 
ploying the  forceps  in  such  cases,  will  fall  soon  to  be  considered. 
An  inefficient  state  of  uterine  action  may  be  produced,  by  some 
other  part  acting  too  much,  or  being  in  a  state  of  irritation  ;  and 
so  long  as  that  continues,  the  womb  cannot  be  expected  to  con- 
tract briskly.  We  ascertain  this  by  examining  the  sensations  and 
state  of  the  patient.  If  the  stomach  be  irritated,  she  is  sick  and  op- 
pressed, and  probably  desponding,  and  sometimes,  almost  at  every 
pain,  has  an  inclination  to  vomit.  The  treatment  must  depend  some- 
what on  a  knowledge  of  the  habitudes  of  the  patient,  with  regard  to 
certain  medicines.  If  opium  agree  with  her,  a  moderate  dose 
alone,  or  with  some  aromatic,  is  useful  j  a  little  spirit  of  lavender, 
or  a  glassful  of  hot  water,  or  a  little  hartshorn,  may  be  employed, 
orAe  epigastric  region  rubbed  with  some  stimulant  embrocation. 
Vomiting,  without  distressing  sickness,  and  not  dependant  on  ex- 
haustion, but  occurring  early  in  labour,  often  excites  rather  than 
retards  the  action.  In  other  cases,  the  bowels  suffer,  and,  in 
these,  twenty  drops  of  laudanum  generally  give  relief.  A  dis- 
tended bladder  also  is  a  cause  of  protracted  labour.  In  other 
cases,  the  muscles  of  the  back  or  belly  become  painfully  affected, 
producing  what  Daventer  called  "  wild  and  wandering  pains,"  or 
that  state  in  which  the  pains  no  sooner  seem  to  come  on  than  they 
"  are  changed  into  a  colic,  or  a  cramp,  and  an  impotency  of  la- 
bour." In  such  cases  he  forbade  forcing  medicines,  and  advised 
anodynes.  This  advice  is  a  good  one }  and,  in  all  these  cases, 
twenty-five  drops  of  laudanum  will  be  useful,  at  the  same  time 
that  the  pained  part  be  rubbed  with  the  hand,  or  an  embrocation. 
In  cases  of  muscular  pain,  walking  or  change  of  posture  often  gives 
relief;  when  there  is  no  particular  organ  or  part  affected,  but  only 
a  general  irritation,  attended  with  teazing  inefficient  pains,  the 
same  remedy^is  often  of  service,  and  the  energy  is  directed  pre- 
sently to  the  uterus.  In  all  those  kinds  of  cases,  it  is  also  useful, 
in  general,  to  endeavour  to  excite  the  uterus  itself  by  a  warm  sa- 
line enema,  or  by  some  of  the  other  means  already  or  still  to  be 
mentioned,  or  by  rubbing  the  uterine  region  itself.  This  has  been 
particularly  recommended  by  Mr.  Power,  who  has  insisted  more 
than  any  other  writer  on  metastasis  of  action,  and  on  the  utility  of 


421 

this  remedy,  in  exciting  uterine  action.  He  employs  it  by  draw- 
ing  the  ringers  and  thumb  rapidly  together  over  the  uterus  so  as  to 
make  a  brisk  friction  on  the  part.  That  general  agitation  of  the 
muscular  system  known  under  the  name  of  rigor,  which  often  at- 
tends the  first  stage  of  labour,  if  carried  too  far,  or  continued  too 
long,  may  also  retard  delivery,  but,  in  general,  it  goes  off  spon- 
taneously, and  the  action  concentrates  more  powerfully  in  the  ute- 
rus. Hence,  it  is  a  practical  remark,  that  these  rigors  often  are 
followed  by  a  brisk  labour.  This  effect,  and  consequently  the 
propriety  of  interfering,  must  depend  on  their  prolongation,  and 
on  their  influence  in  carrying  off  the  uterine  pain.  When  we  re- 
quire to  interpose,  the  practice  is  similar  to  that  recommended 
above  for  allaying  general  irritation. 

In  tedious  labour,  it  is  not  necessary  to  confine  the  woman  to 
bed,  or  to  one  posture  ;  she  may  be  allowed  to  sit,  lie,  or  walk, 
as  she  feels  inclined ;  and  we  are  not  to  urge  her  to  stand  long,  or 
use  exertion  by  way  of  promoting  labour.  She  has  generally  not 
much  inclination  for  food,  but,  if  the  process  be  protracted,  it  is 
useful  to  give  some  light  soup,  and  a  little  wine,  if  she  desire  it. 
If  the  urine  be  not  regularly  passed  in  tedious  labour,  the  cathe- 
ter ought  to  be  introduced.  It  is  not  necessary  that  the  practitioner 
remain  constantly  with  the  patient.  It  will  have  a  better  effect 
upon  her,  if  he  see  her  at  proper  intervals  ;  whilst  he  is  thus  pre- 
vented himself  from  being  so  fatigued,  as  he  otherwise  would  be, 
and  is  therefore  better  able  to  discharge  his  duty  with  firmness 
and  judgment. 

The  second  general  cause  of  tedious  labour  is  irregular  action 
of  the  uterine  fibres.  After  the  child  is  born,  the  uterus  some- 
times contracts  like  a  sand-glass,  and  retains  the  placenta.  The 
same  spasmodic  action  may  occur  before  the  child  be  expelled. 
Many  causes,  and  some  of  them  obscure,  may  excite  the  spas- 
modic action :  it  is  apt  to  take  place  when  the  membranes  have 
given  way  prematurely,  and  before  the  os  uteri  be  in  a  relaxed 
state,  or  have  begun  to  dilate.  Improper  irritation  of  the  os  uteri 
often  excites  it,  especially  attempts  to  dilate  it  in  absence  of  a 
pain,  or  hurriedly  during  one.  Letting  out  the  water,  when  the 
uterus  is  not  contracting-  and  where  there  is  no  pain  at  the  time, 


422 

may  also  cause  it,  probably  by  allowing  the  lower  part  of  the 
uterus  to  collapse  suddenly  around  the  head  or  presentation.  Pre- 
ternatural distension  of  the  womb  may  also  produce  it,  even  pre- 
vious to  the  discharge  of  the  water.  Irritation  of  the  bowels,  and 
mental  anxiety  may  also  be  viewed  as  causes  of  spasmodic  action. 
It  is  marked  by  pain  coming  or  increasing  at  intervals,  like  pro- 
per pains,  but  it  is  confined  to  the  belly,  and  has  little  effect  on 
the  os  uteri,  or  in  forcing  down  the  child,  nay  the  os  uteri  some- 
times seems  even  to  contract  during  a  pain.  The  pain  does  not 
go  entirely  off  as  in  natural  labour ;  but  the  patient  complains  of 
constant  uneasiness  in  the  back,  or  some  part  of  the  belly,  but 
generally  in  the  former.  The  contraction  does  not  go  off  with  the 
pain,  it  only  lessens;  hence  the  band  of  fibres  still  compresses  the 
child,  or  ovum,  and,  if  the  membranes  have  not  broken,  they  are 
often  kept  so  tense,  as  at  first  to  resemble  a  part  of  the  child,  and 
may  mislead  the  practitioner  with  respect  to  the  presentation. 
There  is  often  a  frequent  desire  to  void  urine,  and  the  spirits  are 
generally  depressed.  If  this  affection  be  slight,  it  may  soon  go 
off;  but,  if  the  spasm  be  strong,  it  sometimes  continues  for  many 
hours.  A  smart  clyster  is  often  of  great  service.  Blood-letting 
sometimes  does  good,  but  I  prefer  opening  the  membranes  if  the 
presentation  be  good,  and  the  os  uteri  lax  ;  this  I  have  found  very 
successful. 

If,  on  the  contrary,  the  os  uteri  be  rigid  or  undilated,  and  espe- 
cially if  the  presentation  be  not  determined,  they  must  be  kept  en- 
tire, until  the  os  uteri  will  permit  of  turning,  should  the  position  of 
the  child  require  it.  In  such  cases,  and  even  when  the  state  of  the 
os  uteri  has  warranted  the  rupture  of  the  membranes,  but  the  ex- 
pected benefit  has  not  accrued,  we  may  derive  advantage  from 
giving  a  large  dose  of  opium  ;  for  in  this  spasm,  like  tetanus, 
opium  may  be  given  safely  in  prodigious  doses.  Even  ten  grains 
have  been  given,  but  in  general  four  are  sufficient ;  or  an  anodyne 
clyster  may  be  employed.  After  the  child  is  born,  the  hand  should 
be  introduced  into  the  uterus,  not  to  extract  the  placenta  quickly, 
but  to  come  easily  in  contact  with  it,  and  excite  the  uterus  to  regu- 
lar action ;  for  generally  the  spasm  returns,  and  the  placenta  may 
be  long  retained,  or  hemorrhage  produced. 


423 

A  frequent  cause  of  tedious  labour,  is  a  state  of  over-action  or 
unproductive  action  in  the  first  stage,  by  which  the  powers  of  the 
uterus  are  exhausted,  and  the  subsequent  process  is  rendered  very- 
slow.  This  exhaustion  may  also  be  produced  by  the  continuance 
of  debilitated  action,  or  feeble  and  useless  pains.  In  the  first  case, 
the  pains  are  sharp  and  frequent,  but  do  not  dilate  theos  uteri  pro- 
perly, nor  advance  the  process  in  general.  It  may  be  produced  by 
irregular  action  of  the  fibres,  or  by  premature  rupture  of  the  mem- 
branes. In  the  second  case,  the  pains  are  lingering,  short,  and 
usually  weak.  I  have  already  considered  the  remedies  for  these 
states  ;  blood-letting,  clysters,  gentle  dilatation  of  the  os  uteri,  &c. 
and  have  here  only  to  observe,  that  the  exhaustion  of  the  uterus, 
and  consequently  an  additional  prolongation  of  the  labour,  is  to  be 
prevented,  either  by  suspending  the  pains  for  a  time,  or  by  ren- 
dering them  more  effective  ;(x)  and  upon  this  subject,  I  refer  to 
what  I  have  already  said  in  the  beginning  of  this  chapter.  Unpro- 
ductive action  ought  never  to  be  allowed  to  continue  so  long  as 
materially  to  impair  the  action  of  the  womb.  If  we  cannot  safely 
render  the  action  more  efficient,  we  must  endeavour  to  suspend  it; 
by  which  the  womb  recruits,  and  the  retarding  cause  may  in  the 
mean  time  be  removed,  or  cease  to  exist. 

Another  cause  of  tedious  labour  is  the  accession  of  fever,  with 
or  without  local  inflammation.  Fever  is  recognised  by  its  usual 
symptoms,  and  may  be  produced  by  the  injudicious  use  of  stimu- 
lants, heated  rooms,  irritation  of  the  parts,  &tc.  It  is  to  be  allayed 
by  opening  the  bowels,  keeping  the  patient  cool  in  bed,  and  giving 
some  saline  julap ;  at  the  same  time  that  the  mind  is  to  be  tran- 
quillized. If  these  means  do  not  immediately  abate  the  heat,  fre- 
quency of  pulse,  &c.  and  render  the  pains  more  effective,  it  will 
generally  be  proper  to  detract  blood,  especially  if  the  head  or  chest 
be  pained.  When  local  inflammation  accompanies  fever,  it  is  com- 
monly of  the  pleura,  or  peritoneum,  or  vagina.  The  first  is  dis- 
covered by  pain  in  the  thorax,  cough,  and  dyspnoea ;  the  second 
by  pain  in  the  belly,  gradually  increasing  and  becoming  constant ; 

fxj  Which  may  frequently  be  safely  done  by  the  judicious  use  of  the  ergot, 
or  spurred  rye. 


424 

pressure  increases  it,  and  in  some  time  the  patient  cannot  lie  down, 
but  breathes  with  difficulty,  or  is  greatly  oppressed,  and  vomits. 
The  labour  pains  are  sometimes  suspended ;  on  other  occasions, 
they  do  ultimately  expel  the  fetus,  but  the  woman  dies  in  a  few 
hours.  On  the  first  appearance  of  these  symptoms,  blood  should 
be  freely  detracted,  the  bowels  opened,  and  a  gentle  perspiration 
excited.  In  all  these  cases  of  inflammation,  if  immediate  relief  be 
not  obtained,  the  child  must  be  delivered  by  ,he  forceps.  If  the 
vagina  be  hot  and  dry,  we  are  also  to  deliver  immediately,  as  these 
symptoms  indicate  danger  from  inflammation.* 

Labour  may  also  be  rendered  tedious,  by  the  different  stages  not 
going  on  regularly,  but  efforts  being  prematurely  made  to  bear 
down.  In  consequence  of  these,  the  uterus  descends  in  the  pelvis 
before  the  os  uteri  is  dilated,  and  the  process  is  often  both  painful 
and  protracted.  In  some  cases,  the  womb  prolapses,  so  that  its 
mouth  appears  at  the  orifice  of  the  vagina.  This  prolapsus  may 
take  place  during  pregnancy,  or  after  parturition  begins.  It  is  of- 
ten met  with,  in  a  slight  degree,,  whilst  the  os  uteri  is  not  greatly 
dilated,  and  uniformly  injures  the  labour.  We  are  to  prevent  it  from 
increasing,  by  supporting  the  head  or  the  uterus  with  two  fingers, 
during  the  continuance  of  a  pain  ;  at  the  same  time  that  the  woman 
avoids,  as  much  as  possible,  every  bearing-down  effort,  and  re- 
mains in  a  recumbent  posture.  If  the  os  uteri  be  slow  of  dilating, 
some  blood  should  be  taken  away,  and  an  opiate  administered,  or 
the  os  uteri  gently  but  completely  dilated,  during  successive  pains. 
It  has  happened  that,  by  neglecting  these  precautions,  the  uterus 
has  protruded  beyond  the  external  parts.  In  this  case,  no  time  is 
to  be  lost  in  attempting  the  reduction,  which  will  be  rendered  easier 

*  It  is  observed,  generally,  that  women  in  labour  bear  well  the  loss  of  blood. 
Bleeding,  undoubtedly,  when  used  judiciously,  facilitates  the  expulsion  of  the 
child,  and  secures  a  more  speedy  recovery,  or  "getting  up."  It  moreover  ob- 
viates the  train  of  unpleasant  consequences  to  which  women  are  liable  from  the 
tendency  in  their  systems  to  inflammation  at  the  time.  As  a  remedy  to  suspend 
uterine  action  with  a  view  of  turning  the  child,  bleeding  is  never  to  be  neglected, 
provided  the  woman  is  not  exhausted.  But  when  it  does  not  produce  that  effect, 
which  will  often  happen,  then  opium  in  a  large  dose  may  be  resorted  to  with  ad- 
vantage.  It  is  correct  practice,  however,  in  most  cases  to  let  bleeding  precede 
the  anodyne.    C. 


4£5 

by  cautiously  pulling  back  the  perineum.*  If  this  cannot  be  done, 
the  os  uteri,  if  lax  and  yielding,  must  be  gently  further  dilated,  the 
membranes  ruptured,  the  child  turned,  and  the  uterus  replaced.f 
The  os  uteri  has  been  cut,J  but  this  can  never  be  necessary  if  the 
structure  of  that  part  be  natural.  When  the  womb  does  not  actu- 
ally protrude,  the  vagina  may  be  inverted  like  a  prolapsus  ani.  A 
soft  cloth,  dipped  in  oil,  should  be  placed  on  the  part,  and  pressure 
made  with  the  hand.  Giesman  cut  the  inverted  vagina  on  a  probe, 
but  this  operation  can  rarely  be  required.  If  the  womb  prolapse 
before  labour,  as  happened  to  Rxederer's  patient,  we  must  manage 
the  case  as  a  simple  prolapsus.  She  had  severe  pains,  although 
^he  was  not  in  labour. 

ORDER  2.  FROM  SOME  MECHANICAL  IMPEDIMENT. 

There  exists,  naturally,  such  a  proportion  between  the  size  of  the 
head  and  the  capacity  of  the  pelvis,  that  the  one  can  pass  easily 
through  the  other.  But  this  proportion  may  be  destroyed,  either 
by  the  head  being  larger  or  more  completely  ossified,  or  the  pelvis 
smaller  than  usual.  In  such  cases,  which  are  to  be  discovered  by 
careful  examination,  it  is  evident  that  the  labour  must  be  more  te- 
dious, and  more  painful,  than  it  otherwise  would  be.  The  first 
stage  of  the  process  is  generally,  but  not  always  slow;  the  second 
is  uniformly  so  ;  the  head  is  long  of  descending  into  the  pelvis,  it 
rests  long  on  the  perineum,  the  pains  are  frequent,  severe,  and  often 
at  last  very  forcing,  but  the  woman  says  they  are  doing  no  good-. 
Now  this  state  requires  both  patience  and  discretion.  The  bowels 
should  be  opened  with  a  laxative ;  the  urine  regularly  expelled  ; 
the  strength  preserved  by  quietness,  avoiding  unnecessary  exer- 
tion, indulging  any  disposition  to  sleep  which  may  exist,  and  taking 
a  little  light  nourishment  occasionally  j  the  mind  is  to  be  soothed, 
and  the  hopes  supported.  The  rule  formerly  laid  down,  with  re- 
gard to  effecting  the  dilatation  of  the  os  uteri,  or  accomplishing  the 

*  Vide  Mem.  of  Med.  Soc.  Vol.  I.  p.  213. 

|  Vide  Portal'9  10th  Obe. ;  and  Ducreux's  case,  in  Mem.  de  l'Acad.  de  Cliir. 
Tome  III.  p.  368.     See  also  a  case  by  Saxtorph. 
iVide  case  by  Dr.  Archer,  New  York  Med.  Rep.  Vol.  I.  p.  323. 

55 


426 

first  stage  of  labour  within  a  certain  period,  is  to  be  attended  to,  by 
which  the  energy  of  the  uterus  is  saved,  and  it  is  enabled  to  go 
through  the  second  stage  more  readily  and  safely.  If  the  pain? 
begin  to  slacken,  whilst  the  strength  remains  good,  an  opiate  may 
be  given,  to  procure  some  rest.  How  long  the  case  may  be  trust- 
ed to  nature,  must  depend  on  the  strength  of  the  patient,  and  the 
degree  of  suffering ;  but,  assuredly,  we  are  not  at  liberty  to  carry 
the  trial  to  a  great  extent.  The  consideration  of  this  question,  how- 
ever, must  be  reserved  for  the  next  chapter. 

Malposition  of  the  head  may  likewise  retard  the  labour ;  but 
this  has  already  been  considered.  Much  suffering  may  be  avoided 
by  attending  to  this  cause,  as  the  position  is  often  rectified  by  pres- 
sure with  the  finger  alone. 

Another  cause  of  tedious  labour  is,  rigidity  of  the  soft  parts,  which 
may  be  dependent  on  advancement  in  life,  or  some  local  peculi- 
arity ;  and  these  causes  generally  act  more  powerfully  in  a  first  than 
a  subsequent  labour.  This  rigidity  may  exist  in  the  os  uteri,  in  the 
external  parts,  or  in  both ;  and  if,  along  with  this,  there  be  prema- 
ture rupture  of  the  membranes,  the  difficulty  is  always  increased. 
When  it  exists  in  the  os  uteri,  that  part  is  very  long  of  dilating  ;  the 
effect  of  the  pains,  for  a  long  time,  is  rather  to  soften  than  to  di- 
late ;  and  after  the  woman  has  been  many  hours  in  labour,  it  is 
found,  when  the  pain  goes  off,  to  be  collapsed,  and  projecting  like 
the  os  uteri  in  the  eighth  month  of  pregnancy.  In  this  case,  the 
first  stage  is  very  slow,  lasting,  if  we  do  not  interfere,  sometimes 
two  or  three  days;  and  the  second  is  likewise  tedious.  The  whole" 
process  takes  up,  perhaps,  three  days  or  more.  When  the  rigidi- 
ty exists  chiefly  or  partly  in  the  external  parts,  they  are  found  to 
be  at  first  dry,  tight,  and  firm.  By  degrees,  they  become  moister 
and  more  relaxed  ;  but  they  may  still  be  so  unyielding,  as  to  keep 
the  head  for  many  hours  resting  on  the  perineum.  Some  methods 
have  been  proposed  for  abating  the  rigidity ;  such  as  baths,  fo- 
mentations, and  oily  applications;  or  digitalis  and  sickening  medi- 
cines given  internally ;  but  these  have  no  good  effects,  and  some 
of  them  do  harm.*  Blood-letting  is  the  best  remedy  in  such  cases. 

*  These  remedies  are  mostly  inefficient  or  injurious.    The  -warm  bath  is  pro- 
ductive of  no  advantage,  and  is  apt  to  detach  the  placenta,  occasioning  thereby 


427 

Dr.  Rush  informs  me,  that  in  America  it  has  been  used  with  great 
advantage  ;  and  Dr.  Dewees  has  politely  sent  me  a  dissertation  on 
this  subject,  which  contains  very  good  cases  of  its  efficacy,  when 
pushed  freely.  In  some  instances,  fifty  ounces  were  taken  before 
the  parts  relaxed.  In  determining  on  the  use  of  blood-letting,  wc 
must  attend  to  the  state  and  habit  of  the  patient.  Debilitated  wo- 
men,* and  those  who  are  exhausted  by  fatigue,  especially  among 
the  lower  classes  in  large  cities,  are  injured  rather  than  benefitted 
by  this  practice.  Robust  women,  of  a  rigid  fibre,  in  the  middle 
class  of  society,  or  who  live  in  the  country,  bear  blood-letting  bet- 
ter, and  derive  more  benefit  from  it.  In  them  it  is  especially  pro- 
per, if  any  degree  of  fever  attend  the  labour,  and  in  whatever  part 
the  rigidity  exists,  if  the  patient  be  not  previously  reduced,  or  very 
delicate,  blood  should  be  detracted  pro  viribus.  If,  however,  the 
state  of  the  patient  forbid  this,  then  an  opiate  clyster  is  the  appro- 
priate remedy. 

The  direction  already  given,  respecting  the  completion  of  the 
first  stage  of  labour  within  a  reasonable  time,  must  be  attended  to, 
and  is  always  practicable  when  the  means  of  relaxation  have  been 
employed.  When  the  head  descends  to  die  perineum,  it  is  of  ser- 
vice to  keep  the  patient  for  some  time  in  an  erect  or  kneeling  pos- 
ture. We  must  not  allow  cither  the  general  or  the  uterine  vigour 
to  be  too  much  diminished,  but  must  finish  the  labour  by  the  for- 
jceps,  before  any  considerable  exhaustion  takes  place. 

iangerous  hemorrhages.  But  I  confess,  my  objections  to  it  arise  rather  from 
what  I  have  learnt  of  others  in  whom  I  can  confide,  than  from  my  own  experi- 
ence, having  rarely  seen  the  bath  employed.  Nauseating  medicines,  of  different 
kinds,  I  have  tried,  but  with  no  good  effect.  Where  the  external  organs  are  ri- 
.^gid,  and  dry,  and  swelled,  local  fomentations,  and  oily  applications,  may,  perhaps, 
be  of  some  service. 

Blood-letting,  if  regulated  by  a  sound  discretion,  is  undoubtedly  the  remedy  in 
\hese  cases.  It  may  often  be  pushed  to  a  considerable  extent.  I  have  drawn  as 
much  as  fifty  ounces  of  blood  in  tixe  course  of  a  day,  or  night,  where  the  os  tines 
obstinately  refused  to  yield.  In  rigidity  of  the  vagina,  owing  either  to  natural  or 
acquired  causes,  and  in  tumefaction  of  the  external  parts,  attended  with  soreness 
to  the  touch,  it  is  equally  useful.     C. 

*  Dr.  Dewees  bleeds  even  delicate  women,  and  those  who  are  disposed  to  fa'mt 
en  being  bled,  but  takes  a_smaller  quantity  from  them. 


428 

In  some  cases,  the  os  uteri  or  external  parts,  instead  of  being 
rigid,  are  tumid,  and  apparently  cedematous.fyj  In  these,  the  la- 
bour is  often  protracted  for  several  hours,  especially  when  the  oS 
uteri  is  affected.  In  tedious  labour,  the  os  uteri  sometimes  becomes 
swelled,  as  if  blood  were  effused  into  its  interstices.  This  requires* 
venesection,  and  then  a  smart  clyster. 

The  os  uteri  may  be  naturally  very  small.  In  some  instances, 
it  has,  with  difficulty,  admitted  a  sewing  needle  ;  and  in  two  cases, 
during  labour,  I  found  it  almost  impervious,  hard,  circular,  and 
with  difficulty  discovered ;  but  it  gradually  dilated.  Venesection 
is,  in  this  state,  of  service.  Sometimes  it  is  hard  and  scirrhous,  so 
that  it  has  been  deemed  necessary  to  make  an  incision  into  the  os 
uteri,  to  make  it  dilate.*    It  is  also  possible  for  the  os  uteri  to  be 

(y_)  A  case  of  this  kind  occurred  not  long  since  to  the  Editor,  where,  in  con- 
sequence of  the  great  tumefaction  of  the  labia  and  parts  in  the  vicinity,  it  be- 
came  necessary  to  have  recourse  to  punctures,  to  prevent  the  bursting  or  lace- 
ration of  the  immensely  distended  integuments.  The  tumefaction  was  so  great, 
that  the  patient  could  only  lay  on  her  back,  with  her  knees  drawn  up,  and  her 
thighs  supported  by  pillows — the  canal  of  the  vagina  was  so  lessened  by  pressure 
from  the  effusion  in  the  surrounding  parts,  that  the  examination  to  discover  the 
state  of  the  labour,  was  made  with  considerable  difficulty.  After  the  punctures 
in  the  labia  (which  jointly  appeared  to  be  as  large  as  a  child's  head,)  were  made, 
the  fluid  continued  oozing  out  for  several  hours,  and  it  was  supposed  by  a  judi- 
cious assistant,  that  nearly  three  pints  of  water  had  been  evacuated.  The  labia 
ultimately  were  completely  reduced,  and  indeed  became  flaccid,  and  the  labour 
then  progressed,  and  was  accomplished  without  any  great  difficulty,  but  the 
child  was  dead. 

*  A  case  of  this  kind  occurred  to  Dr.  Simson  of  St.  Andrews,  and  another  to 
a  practitioner  in  America.  Dubosc  mentions  a  woman  40  years  of  age,  who  had 
convulsions  for  two  days,  during  labour,  from  this  cause.  The  face  was  pale  and 
the  extremities  cold.  The  orifice  was  very  rigid,  and  little  dilated.  He  cut  it 
and  she  was  delivered  of  a  dead  child.  Gautier  mentions  a  case  where,  after  la- 
bour had  continued  15  hours,  no  os  uteri  could  be  found.  The  uterus  had  de- 
scended considerably  in  the  pelvis,  and  there  was  no  reason  to  suppose  the  os 
uteri  was  high  from  obliquity ;  an  incision  was  made,  and  the  child  extracted 
by  the  forceps.  In  6  weeks  the  patient  menstruated,  and  when  examined  after 
that,  the  uterus  was  found  in  an  adherent  state  of  antiversion.  Other  cases  are  to 
be'iiiet  with  in  the  Diet,  des  Sciences  Medic.  Art.  Hysterotomie. 


429 

closed  in  consequence  of  inflammation,  so  that  it  has  been  neces- 
sary to  make  an  artificial  opening.* 

Contraction  and  cicatrices  in  the  vagina,  likewise  retard  labour, 
and  cause  very  great  pain,  until  they  either  relax  or  are  torn,  but 
it  is  seldom  necessary  to  perform  any  operation.  If  it  should, 
they  must  be  cut. 

Excrescences  proceeding  from  the  os  uteri,  an  enlarged  ova- 
rium remaining  in  the  pelvis,  or  tumoursfzj  attached  to  the  liga- 
ments, or  a  stone  in  the  bladder,  may  all  obviously  retard  the  la- 
bour, some  of  them  so  much  as  to  require  instruments.  A  stone 
?n  the  bladder  ought  either  to  be  pushed  up  beyond  the  head,  or 
extracted. 

A  small  vagina  may  require  a  long  timfc  to  be  dilated. 

A  great  degree  of  obliquity  of  the  uterus  protracts  labour.  The 
os  uteri  may  be  turned  very  much  to  one  side,  but  oftener  it  is  di- 

*  Vide  case  by  Campardon  ;  in  Recueil  Period.  Tom.  XII.  p.  227.  Moscati 
gives  a  case  where,  in  consequence  of  injury  by  the  forceps,  the  os  uteri  was  so 
small  that  it  would  not  admit  a  probe.  A  number  of  incisions  were  made  round 
it,  after  which  it  dilated.  In  the  next  pregnancy  slighter  incisions  sufficed,  and 
in  the  last  none  were  required.  Aubertin  performed,  in  a  case  of  the  kind,  the 
cesarean  operation.  In  a  subsequent  pregnancy,  in  the  7th  month,  the  cicatrix 
was  ruptured,  and,  by  very  little  enlargement,  a  child  was  successfully  extracted. 
In  a  case  given  by  Gautier,  the  os  uteri  was  obliterated  after  a  labour  in  which 
the  shoulder  presented.  The  menses  were  retained,  and  required  a  perforation 
for  their  evacuation. 

(z)  Two  very  interesting  papers  on  tumours  within  the  pelvis,  obstructing  par- 
turition, have  been  published  of  latter  years  ;  the  first  by  H.  Parke,  esq.  of  Li- 
verpool, in  the  2d  Vol.  of  the  Medico-chirurgical  Transactions,  and  also  in  the 
Eclectic  Repertory,  Vol.  IV.  The  next  and  the  most  important  memoir  is  by 
Dr.  Merriman,  in  the  Medico-chirurgical  Transactions,  Vol.  X. 

It  would  appear  from  the  cases  related  or  referred  to  in  these  papers,  that 
Embryulcia  and  the  Crochet  can  be  rarely  necessary  in  such  instances. 

From  the  evidence  we  at  present  possess,  as  has  been  observed  by  Mr.  Parke 
and  Dr.  Merriman,  the  most  eligible  practice  would  generally  appear  to  be,  to 
puncture  the  tumour,  or  to  make  an  incision  into  it,  which  gives  both  the  mo- 
ther and  child  the  best  chance  of  existence.  In  the  case  related  by  Professor 
Francis,  in  a  note  to  his  valuable  edition  of  Denman's  Introduction,  it  neverthe- 
less appeared  to  be  necessary,  after  puncturing  and  breaking  down  the  tumour, 
to  deliver  by  the  crotchet.  The  woman  recovered,  and  again  became  preg- 
nant. 


430 

reeled  backwards  and  upwards,  and  may  be  out  of  the  roach  of 
the  fiuger.  Time  rectifies  this,  but  much  time  and  pain  may  be 
spared,  by  gently  pressing  the  os  uteri  forward  with  the  finger. 
Daventer,  who  was  both  a  candid  and  an  experienced  man,  has  per- 
haps made  the  moderns  too  inattentive  to  obliquity  of  the  womb, 
by  going  to  the  opposite  extreme. 

Retroversion  of  the  uterus  may  likewise  prove  a  cause  of  te- 
dious labour,  and  can  only  be  remedied  by  cautiously  attempting 
to  press  down  the  os  uteri  from  above  the  pubis. 

Malformation  of  the  organs  of  generation  may  afford  great  ob- 
stacles to  the  passage  of  the  child,  so  that  even  an  incision  may  be 
required,  as  happened  in  the  case  related  by  Mr.  Bonnet,  in  the. 
thirty-third  volume  of  the  Philosophical  Transactions. 

By  shortness  of  the  umbilical  cord,  or  still  more  frequently,  by 
the  cord  being  twisted  round  the  neck,  the  labour  may  be  retard- 
ed, particularly  the  latter  end  of  the  second  stage.  The  cord 
may  be  on  the  stretch,  but  it  never  happens  that  it  is  torn,  and 
very  seldom  that  the  placenta  is  detached.  We  have  no  certain 
sign  of  the  existence  of  this  situation ;  but  there  is  presumptive 
evidence  of  it,  when  the  head  is  drawn  up  again  upon  the  reces- 
sion of  each  pain. (a)  It  often  remains  long  in  a  position,  which 
we  would  expect  to  be  capable  of  very  quick  delivery.  By  pa- 
tience, the  labour  will  be  safely  terminated  ;  but  it  may  often  be 
accelerated,  by  keeping  the  person  for  some  time  in  an  erect  pos- 
ture, on  her  knees.  After  the  head  is  born,  it  is  usual  to  bring 
the  cord  over  the  child's  head,  so  as  to  set  it  at  liberty  ;  and  tins 
is  very  proper  when  it  can  easily  be  done,  as  it  prevents  the  neck 
from  being  compressed  with  the  cord  in  the  delivery  of  the  child, 
by  which  the  respiration,  if  it  had  begun,  would  be  checked,  or 
the  circulation  in  the  cord  be  obstructed.  Some  have  advised  that 
the  cord  should  be  divided,  after  applying  the  double  ligature  ;  but 

(<i)  This  retraction  of  the  head  during  the  recession  of  a  pain,  is  more  fre- 
quently owing  to  the  rigidity  of  re-action  of  the  external  parts ;  and  may  often 
be  obviated  if  necessary,  by  venesection.  We  believe  it  is  rarely  owing  to  the 
cause  here  assigned  for  it  by  our  author. 


431 

this  is  rarely  necessary,  for  the  child  may  be  born,  even  although- 
the  cord  remain  about  the  neck,(6J 

Preternatural  strength  of  the  membranes  may  also  to  a  certain* 
ty  prove  a  cause  of  tedious  labour.  This  is  at  once  obviated,  by 
tearing  them,  which  is  done  by  laying  hold  of  them  when  slack, 
during  the  remission  of  the  pains.  It  sometimes  requires  a  con- 
siderable effort  to  rupture  them. 


CHAP.  VI, 

Of  Instrumental  LaboUr. 

ORDER  1.  CASES  ADMITTING  THE  APPLICATION  OF  THE 
FORCEPS  OR  LEVER. 

Various  causes  may  render  it  necessary  to  accelerate  delivery,, 
such  as,  spitting  of  blood,  convulsions,  uterine  hemorrhage,  em- 
physema, the  existence  of  aneurism,  &tc.  These  are,  however,  to 
be  considered  as  in  some  respects  adventitious  ;  and,  at  present,- 
I  mean  to  confine  myself,  to  an  account  of  those,  which  are  more 
immediately  connected  with  the  power  of  expulsion. 

It  must  be  very  evident,  that  if  the  head  of  the  child  be  unusu- 
ally large,  or  the  capacity  of  the  pelvis  be  diminished,  a  mechanical 
obstacle  must  arise  to  the  delivery  of  the  child.  Of  these  two 
states  the  last  is  by  far  the  most  frequent,  and  constitutes  one  pro- 
minent cause  of  instrumental  labour.  I  have  already  explained, 
the  effect  of  resistance  in  checking  the  free  and  brisk  action  of  the 
uterus,  until,  at  last,  the  muscular  power  is  more  roused,  and  strong 
efforts  made.     These  circumstances  require  to  be  maturely  consi- 

(6)  In  some  cases  where  it  has  been  found  impracticable,  without  great  dan- 
ger of  rupturing  the  cord,  to  bring  it  over  the  head  of  the  child,  it  has  an- 
swered to  pass  it  over  the  shoulders  of  the  infant,  and  thus  suffer  it  to  be  born 
through  the  uo«sc  of  the  cord . 


432 

dared,  for,  in  such  cases,  the  first  stage  of  labour  is  very  frequently, 
although  not  invariably,  slow;  and  if  not  accelerated  by  proper 
management,  the  action  of  the  uterus  is  apt  to  become  exhausted, 
and  its  vigour  prove  inadequate  to  the  safe  accomplishment  of  the 
second  stage.  Different  effects  must  be  produced  by  the  resist- 
ance, according  to  its  degree,  the  constitution  of  the  patient,  and 
concomitant  circumstances.  A  slight  opposition  may  operate,  chiefly 
by  impeding  or  rendering  irregular  and  inefficient  the  action  of  the 
uterus,  and  the  consequences  may  vary  much  in  different  labours, 
and  under  different  treatment.  A  greater  degree  of  resistance  must 
invariably  produce,  from  the  obstacle  afforded,  a  protracted  and 
severe  labour  ;  and,  in  particular,  we  apprehend  the  occurrence  of 
two  different  conditions  which  are  very  often  conjoined.  First, The 
head,  by  the  gradual  and  severe  efforts  of  the  uterus,  and  abdomi- 
nal muscles,  is  pressed  more  or  less  into  the  pelvis,  and  becomes 
impacted  there,  so  that  it  cannot,  by  the  power  of  nature,  be  forced 
lower,  and  can  even  with  difficulty,  in  many  cases,  be  raised  in 
any  degree  upward  by  the  accoucheur.  This  is  known  techni- 
cally under  the  name  of  the  locked  head,  or  case  of  impaction.  It 
is  evident,  that  in  this  state  delivery  is  next  to  hopeless,  for  all 
farther  efforts  are  generally  unavailing.  Secondly,  The  continued 
pressure  of  the  head  on  the  soft  parts,  is  productive  of  farther  dimi- 
nution of  the  capacity  of  the  pelvis,  for  inflammation  is  excited, 
and,  at  the  same  time,  the  return  of  blood  by  the  veins  is  obstructed, 
and  of  serum  by  the  lymphatics.  This  impairs  the  power  of  the 
soft  parts,  and  renders  the  inflammation  of  the  low  kind,  so  that, 
even  when  delivery  is  accomplished,  sloughing  succeeds,  whereby 
very  dreadful  or  loathsome  effects  are  produced,  if  these,  indeedj 
be  not  prevented  by  the  death  of  the  patient,  in  consequence  of  a 
similar  low  inflammation  being  communicated  to  the  uterus  or  peri- 
toneum. This  swelling  of  the  parts  contained  within  the  pelvis 
may  take  place,  although  the  head  be  not  impacted,  but  the  head 
cannot  be  long  impacted  without  producing  that.  Here,  then,  is 
one  effect  of  a  most  formidable  and  alarming  nature,  which  we  ap- 
prehend in  the  case  under  consideration.  But  this  is  not  the  whole 
of  the  evil ;  for  the  upper  part  of  the  vagina  or  the  cervix  uteri, 
may  be  lacerated  in  consequence  of  this  debilitated  state,  or  any 


433 

part  of  the  uterus  may  be  ruptured  by  strong  or  spasmodic  action  ; 
or  uterine  or  peritoneal  inflammation  may  be  excited  previous  to 
delivery,  proving  fatal  in  a  few  hours  after  labour  is  terminated  ; 
or  hemorrhage  may  occur  to  a  xatal  degree  from  Want  of  energy  in 
the  uterus  after  delivery  ;  or  general  irritation  and  exhaustion  are 
produced,  the  pulse  becomes  frequent  and  at  last  feeble,  the  mouth 
parched,  the  skin  hot,  the  mind  confused  and  the  strength  sunk;  or 
the  powers  of  life  may  be  worn  out,  so  that  the  patient  shall  die  with- 
out any  decided  inflammation,  or  disease  referrible  to  a  common 
nosological  system.  Such  may,  and  must,  in  general,  be  the  result,  if 
assistance  be  long  withheld,  or  if  the  patient,  from  unusual  strength, 
or  some  fortunate  yielding  of  the  cranial  bones,  be  able  at  last  to 
bring  forth  her  child.  When  we  turn  from  the  mother  to  the  foetus, 
we  find  that  this  continued  pressure  alters  the  shape  of  the  head, 
and  affects  the  action  of  the  brain,  or  the  important  function  of  cir- 
culation :  first,  the  scalp  tumifies,  and  we  think  the  head  is  descend- 
ing, when  in  reality  it  is  stationary,  and  the  integument  is  only 
becoming  raised  ;  then,  the  bones  are  squeezed  closer  together, 
and  the  presenting  part  of  the  cranium  forms  an  angle,  more  or  less 
acute,  which  has  been  compared  to  a  sow's  back.  In  some  in- 
stances, the  two  parietal  protuberances  are  not  more  than  two 
inches  and  a  half  distant  from  one  another,  but  the  head  is  not  al- 
ways lengthened  in  the  same  proportion ;  on  the  contrary,  in  a 
few  cases,  it  is  even  shortened,  from  one  bone  sliding  under  ano- 
ther. Children  have  been  brought  to  me,  where  the  bones  have 
been  separated,  and  the  one  parietal  bone  forced  completely  be- 
neath the  other.  Last  of  all,  partly  from  pressure  on  the  brain, 
but  independently  of  that,  from  continued  pressure  on  the  cord  or 
organs  of  circulation,  the  child  perishes ;  and  whether  born  by 
the  natural  efforts,  or  delivered  by  art,  is  dead.  Such,  then,  are 
the  effects,  to  parent  and  child,  of  a  locked  head ;  effects  which 
can  only  be  avoided  by  accelerating  the  progress  of  labour,  and 
calling  in  the  aid  of  extraneous  force. 

When  we  talk  of  a  case  of  impaction,  we  must  not,  however, 
suppose  that  the  head  is  literally  and  entirely  immoveable.  That 
it  is,  in  the  strict  sense  of  the  word,  sometimes  impacted,  and  can- 
not be  moved,  is  no  doubt  true  ;  but  more  frequently  the  hand  can 

56 


434 

make  it  recede  a  little,  although  the  uterus  cannot  make  it  advance 
any  more.     Levret  took  the  word  in  its  strictest  meaning,  and 
imagined  that  the  head  was  jammed  between  two  points  of  the 
pelvis.     Roederer  went  farther,  and  maintained  that  every  part  of 
the  head  was  so  fixed  and  pressed  on,  that  not  even  a  needle  could 
be  passed  any  where  between  it  and  the  pelvis.     If  so,  how  can 
the  forceps  be  applied?  If  the  head  be  jammed  at  every  point, 
even  making  allowance  for  the  elasticity  of  its  bones,  we  could 
not  introduce  the  finger  between  it  and  the  pelvis,  or  reach  the  ear. 
We  can  be  at  no  loss  to  ascertain  the  existence  of  this  state.     The 
slow  progress  of  the  labour,  the  severity  of  the  pains,  the  tardy 
descent  of  the  head,  its  gradual  impaction,  or  increasing  immo- 
bility, its  alteration  of  shape,  the  deformity  or  diminished  capacity 
of  the  pelvis,  the  progressive  tumefaction  of  the  vagina,  the  station- 
ary condition  of  the  head ; — all  point  it  out,  too  clearly  to  be  mis- 
taken ;  and  many  of  these  symptoms,  together  with  those  of  gene- 
ral irritation  and  exhaustion,  increase  with  the  period  to  which 
labour  is  allowed  to  extend.     This  state  may  be  anticipated,  when 
the  pelvis  is  ascertained  to  be  deformed.     We  know  that  if  the 
pelvis  measure,  in  its  diameter,  only  three  inches  and  a  half,  then 
we  must  have  a  painful  and  difficult  labour,  because,  as  the  head 
measures  as  much  in  its  lateral  extent,  it  must  be  compressed  more 
or  less  in  order  to  pass.     If  the  brim,  however,  measure  somewhat 
less,  the  head  of  a  child,  at  the  full  time,  cannot  pass,  until  it  have 
been  pressed  so  long  as  to  diminish  its  breadth,  perhaps  half  an 
inch.*     The  more,  then,  that  the  brim  is  reduced  below  its  natu- 
ral dimensions,  the  longer  and  more  painful  must  the  labour  be, 
until  we  come  to  such  a  degree  of  contraction,  as  will  either  ren- 
der expulsion  altogether  impossible,  or  delay  it  until  great  danger 
have  been  induced. 

It  is  difficult  to  draw  the  line  of  distinction  betwixt  that  degree 
of  contraction  which  will  render  it  impossible  for  delivery  to  take 

*  The  head  can  bear  much  more  pressure  before  the  child  is  born,  than  after 
it  has  breathed.  Respiration  is  more  under  the  influence  of  the  brain,  than  the 
action  of  the  heart  is ;  and  the  action  of  the  latter,  after  birth,  ceases  when  the 
brain  is  injured  or  compressed,  not  so  much  because  it  is  directly  affected,  as 
because  respiration,  with  which  it  is  associated,  ceases. 


435 

place  naturally,  and  that  which  will  only  render  it  extremely  diffi- 
cult. It  has  been  proposed  to  ascertain  this,  by  a  rule  founded 
on  the  dimensions  of  the  pelvis.  But  this  method  cannot  be  brought 
to  a  sufficient  degree  of  perfection,  for  the  result  of  cases  is  much 
influenced  by  the  size  of  the  child,  the  pliability  of  its  head,  the 
vigour  of  the  uterus,  and  other  causes.  Besides,  it  is  difficult,  if 
not  impossible,  to  determine,  with  minute  precision,  the  dimensions 
of  the  pelvis  in  the  living  subject;  and  they  are  apt  to  vary,  accord- 
ing as  the  soft  parts  within  the  pelvis,  are  more  or  less  swelled. 

There  is  another  case  of  protracted  labour  requiring  instrumen- 
tal aid,  when  the  head  is  not  impacted  ;  the  pelvis  may  even  be 
of  ample  size.  It  is  known  under  the  name  of  the  case  of  arrest, 
or  by  the  French  writers  la  tete  arretee  au  passage.  The  head  is 
not  fixed  or  jammed,  the  finger  can  more  readily  be  passed  round 
it,  the  scalp  may  be  swelled,  but  the  bones  are  never  misshapen,  and 
the  retardation  appears  to  arise  rather  from  the  nature  of  the  pains, 
or  the  unyielding  state  of  the  soft  parts  at  the  outlet  of  the  pelvis, 
than  from  any  actual  obstruction  offered  by  the  pelvis  to  the  deli- 
very. It  is  a  mere  case  of  tedious  labour,  but  a  case  protracted 
to  the  utmost  limits  of  prudence,  in  spite  of  the  employment  of 
those  means  which  have  been  pointed  out  in  the  last  chapter.  It 
may  arise  from  some  slight  disproportion  between  the  size  of  the 
head,  and  the  capacity  of  the  pelvis,  or  more  frequently  from  va- 
riations and  irregularities  of  the  uterine  action,  which  have  al- 
ready been  fully  considered,  and  it  is  much  more  frequent  in  its 
occurrence  than  the  locked  head.  The  case  of  impaction  is  clear- 
ly marked  by  the  symptoms  formerly  detailed :  that  of  arrest  is 
ascertained  by  the  simple  condition  of  the  head  being  stationary, 
but  not  jammed  in  the  pelvis.  There  are  many  cases,  then,  of  ar- 
rest which  are  safely  terminated  by  nature,  and  which  are  placed 
under  the  class  of  tedious  labour;  but  there  are  many  others, 
where  it  becomes  prudent  to  accelerate  delivery  by  artificial  force, 
and  the  question  for  deliberation  is,  at  what  period  we  shall  thus  in- 
terfere, or  when  further  delay  is  hazardous  ? 

I  have  fully,  and  I  hope  practically,  detailed  and  considered  the 
causes  which  render  labour  tedious,  and  have  pointed  out  the  im- 
propriety of  permitting  the  first  stage  to  be  protracted,  for  thereby 


436 

the  uterus  becomes  enfeebled,  and  less  able  to  accomplish  the  se- 
cond. But  when  this  advice  has  not  been  acted  on,  or  when  the 
treatment  proper  for  the  particular  cases  already  described,  has  not 
been  successful  in  effecting  delivery,  what  is  the  consequence  ul- 
timately of  delay  ?  The  uterus,  by  continued,  but  inefficient  action, 
or  unavailing  contraction,  becomes  gradually  debilitated ;  and  when 
at  last  delivery  is  effected,  it  cannot  contract  with  vigour  and  regu- 
larity, whereby  hemorrhage  is  occasioned,  or  the  same  event  is 
produced  by  spasmodic  action  of  the  uterus.  Here  then,  is  one 
very  serious  evil  which  may  be  anticipated.  Next,  there  is  a  strong 
disposition  given  to  puerperal  disease,  not  merely  to  those  trouble- 
some, though  less  dangerous  complaints,  known  under  the  name  of 
weeds,  or  irregular  febrile  paroxysms;  but  also  to  more  formidable 
affections,  of  an  inflammatory  nature,  especially  of  the  womb  or  pe- 
ritoneum. Accordingly,  we  find  that  a  much  larger  proportion  of 
women  die  after  protracted,  than  after  natural,  labour.  Here,  then, 
is  another  class  of  evils  to  be  apprehended.  Again,  although  the 
same  local  mischief  is  not  so  apt  to  take  place,  that  we  meet  with 
in  locked  head ;  yet,  the  patient  is  not  exempted  from  risk  even 
of  that ;  by  continuation  of  labour,  the  soft  parts  at  last  inflame 
and  swell,  which  adds  not  only  to  the  difficulty  of  delivery,  but  al- 
so greatly  to  the  danger  of  the  case.  If  it  be  necessary  to  enume- 
rate other  hazards,  I  may  set  down  the  consequence  of  protracted 
irritation  and  exertion,  marked  by  the  induction  of  a  state  of  fever, 
and  at  last  of  great  exhaustion,  insomuch  that  the  patient  may  ac- 
tually die  undelivered,  but  this  event,  as  well  as  rupture  of  the  ute- 
rus, is  less  apt  to  occur  than  in  locked  head.  Besides  all  these  ha- 
zards to  the  mother,  the  child  is  in  danger  of  perishing,  not  from 
compression  of  the  brain,  but  from  the  continued  pressure  of  the 
uterus,  after  the  evacuation  of  the  water,  interfering  with  the  regu- 
lar performance  of  the  function  of  circulation.  These  are  surely  no 
trivial  evils  resulting  from  protracted  labour  ;  and  the  utmost  that 
I  feel  at  liberty  to  concede  in  favour  of  delay,  is,  that  it  may  be  per- 
mitted longer  in  cases  of  arrest,  than  of  impaction.  Many  eminent 
men,  have  placed  an  undue  confidence  in  the  power  of  nature,  and 
have  been  hostile  to  the  use  of  instruments.  For  a  long  time  I  was 
influenced  by  the  high  authority  and  plausible  arguments,  as  well 


437 

.as  bold  assertions  of  these  practitioners,  but  experience  has  com- 
pelled me  to  adopt  the  opinion,  I  am  now,  with  a  firm  and  solemn 
belief  of  its  correctness  and  importance,  to  maintain  in  this  chapter. 
From  the  strength  of  the  recommendations  of  the  partizans  of  na- 
ture, we  should  suppose,  that  whenever  the  child  could  actually  be 
born  without  aid,  no  hazard  occurred,  and,  on  the  other  hand,  that 
instruments  must  of  necessity  prove  not  only  very  painful  in  their 
application,  but  dangerous  in  their  effects.  Now,  the  first  supposi- 
tion is  notoriously  wrong,  for  innumerable  instances  are  met  with, 
where  the  mother  does  bear  her  child,  without  artificial  aid,  and 
much,  doubtless,  to  the  temporary  exultation  of  the  practitioner, 
but  nevertheless  death  takes  place,  or,  at  the  best,  a  tedious  and 
bad  recovery  is  the  consequence.     The  second  supposition  is  just 
as  positively  unjust ;  for  in  the  majority  of  cases,  if  the  practitioner 
be  humane  and  gentle,  the  introduction  of  the  instrument  gives  lit- 
tle or  no  pain ;  in  so  much  so,  that  in  many  books  we  meet  with 
strong  and  just  reprehension  of  the  clandestine  and  unnecessary 
use  of  instruments,  which  could  never  possibly  take  place,  if  their 
application  were  attended  in  such  cases  with  much  pain.     Then, 
as  to  the  pain  occasioned  by  extraction,  that  may  be  greater  than 
the  patient  was  just  before  suffering,  and  yet  not  be  greater  than  is 
often  experienced  in  a  natural  labour ;  or  even  granting  it  to  be  uni- 
formly greater,  a  concession  I  make  for  the  sake  of  argument,  it  is 
but  for  a  short  time,  and,  on  the  whole,  the  suffering  of  the  patient  is 
less  than  if  nature  had  been  allowed  at  length  to  expel  the  child. 
These  positions  are  perfectly  correct  in  all  cases  of  arrest,  when  the 
practitioner  is  well  instructed  and  cautious.     Next,  as  to  the  dan- 
ger to  be  apprehended,  I  cannot  in  cases  of  arrest  see  any  source 
whence  it  can  arise.     The  mere  introduction  of  the  forceps,  if 
gently  accomplished,  can  scarcely  be  more  hazardous  than  the  in- 
troduction of  the  finger,  for  no  force  is,  or  ought  to  be  exerted.    If 
there  be  hazard,  it  must  be  in  the  process  of  extraction,  and  this, 
it  is  evident,  can  arise  only,  either  from  pressure  of  the  instrument 
on  the  soft  parts,  or  from  the  head  and  instrument  lacerating  the 
perineum.     The  last  event,  must,  in  genera),  be  the  consequence 
of  want  of  caution,  and  the  first  can  never  be  carried  to  anv  dan- 


438 

gerous  degree  in  a  case  of  arrest,  if  the  operator  know  how  to 
direct  his  efforts. 

In  such  cases,  then  we  may  experience  much  evil,  from  trusting 
too  long  to  nature,  but  add  little  to  the  sufferings,  even  for  a  short 
time,  of  the  patient,  and  nothing  to  her  hazard.  When,  however, 
we  turn  our  attention  to  cases  of  impaction,  the  case  is  different. 
There  is  greater  difficulty  in  introducing  and  fixing  accurately  the 
instrument,  and  doubtless  more  pain  even  in  this  stage  is  given  than 
in  cases  of  arrest.  When  again  we  come  to  act  with  it,  the  suffer- 
ing or  pain  must  be  increased,  even  in  the  hands  of  a  gentle  ope- 
rator, in  proportion  to  the  resistance  to  be  overcome.  The  soft 
parts  have  already  been  pressed  on  during  labour  by  the  head, 
they  must  still  be  pressed  on  to  a  greater  degree  ;  and  even  if  the 
maxim,  that  time  is  equivalent  to  force,  were  acted  on  to  a  certain 
extent,  it  would  be  vain  to  deny  that  there  must  be  both  greater 
suffering  and  greater  danger  than  in  natural  labour,  or  than  in  cases 
of  arrest.  These  sufferings,  and  this  danger,  must  be  in  a  certain 
degree  proportioned  to  the  tenderness  which  has  already  taken 
place  in  the  soft  parts,  and  therefore  may  be  greatly  lessened,  but 
cannot  be  increased  by  an  early  application.  Their  production 
depends  on  the  obstacle  afforded.  When  the  head  has  arrived  at 
a  station  rendering  the  application  of  the  forceps  practicable,  no 
good  can  arise  from  delay ;  we  only  add  unprofi tably  to  the  suffer- 
ing in  the  meantime,  or  lay  the  foundation  of  a  state  which  is  to 
render  the  later  application  of  the  instrument  more  painful  and 
more  hazardous.  When  mischief  arises  from  the  application  of 
the  forceps,  it  always  is  owing  either  to  harsh  and  unskilful  con- 
duct, or  to  the  state  induced  by  delaying  their  use  too  long.  If  it 
require  strong  efforts  to  extract  the  child,  could  that  child  ever 
have  been  born  by  the  power  of  nature,  or  could  the  uterus  and 
abdominal  muscles,  after  long  action,  retain  vigour  sufficient  to 
exert  a  force  equal  to  that  which  is  often  required  to  extract  an 
impacted  head.  Indeed  our  best  writers,  however  fond  they  may 
have  been  of  delay  in  cases  of  arrest,  are  disposed  to  deliver 
whenever  the  head  has  been  locked.  Nothing  can  be  expected 
from  delay  except  sloughing,  and  the  alternative  of  speedy  death, 
or  a  miserable  existence. 


•     459 

Holding  the  opinion  I  have  been  laying  down,  it  is  not  without 
astonishment  and  regret,  that  I  find  Dr.  Osborn  stating,  that  in  a 
•  quiring  the  use  of  the  forceps  "  all  the  powers  of  life  are 
exhausted,  all  capacity  for  farther  exertion  is  at  an  end,  and  the 
mind  as  much  depressed  as  the  body,  they  would  at  length  sink 
together,  under  the  influence  of  such  continued  but  unavailing 
struggles,  unless  rescued  from  it  by  means  of  art."  If  such  a  state 
be  allowed  to  take  place,  even  in  a  case  of  arrest,  but  more  especi- 
ally of  impaction,  it  is  much  to  be  dreaded  that  the  interference  of 
art  shall  prove  as  unavailing  as  the  struggles  of  nature.  Were  this 
the  opinion  only  of  Dr.  Osborn,  I  should  pass  it  in  silence  ;  but 
unfortunately  it  is  the  prevailing  doctrine  of  the  day;  and  the  mo- 
dern disciples  of  the  school  of  patience,  men  of  talent  and  obser- 
vation, carry  their  fears  of  the  mischief  resulting  from  the  use  of 
the  forceps  to  an  extravagant  length,  and  place  a  mistaken  confi- 
dence in  the  efficacy  and  safety  of  a  continued  action  of  the  expul- 
sive powers.  I  have  much  pleasure,  however,  in  strengthening  my 
opinion  with  the  authority  of  Dr.  Hamilton,  the  present  excellent 
Professor  of  Midwifery  in  Edinburgh,  who  has  long  seen  the  hurt- 
ful effect  of  the  temporizing  system,  and  of  Dr.  Osiander,  the  ac- 
tive and  experienced  Professor  in  Gottingen.* 

To  place  the  argument  in  a  yet  stronger  light,  I  shall  examine 
the  result  of  delay,  as  deduced  from  the  tables  published  by  Dr. 
Breen  of  the  cases  occurring  in  the  Dublin  Hospital,  because  these 
are  the  latest  I  have  beside  me,  and  were  published  without  re- 
ference to  any  particular  opinion. 

In  the  course  of  57  years,  78,001   women  were  delivered,  of 

*  In  Dr.  Smellie's  time,  he  calculated  that  the  forceps  were  required  once  in 
125  cases  of  labour ;  since  then  there  has  been  rather  a  deterioration  in  prac 
tice,  so  far  as  delay  is  concerned,  for  the  more  modern  calculations  are  1  in  from 
158  to  188.  One  gentleman,  for  whom  1  have  great  respect,  states,  that  the  for- 
ceps were  not  necessary  in  the  hospital  practice,  above  once  in  728  cases,  and  in 
private  practice,  above  once  in  1000. 

Dr.  Merriman's  practice  comes  ruearer  the  line  of  safety,  for  it  exhibits  1 
in  93.  Dr.  Naglee  has  employed  them  once  in  about  53  cases,  which  corres- 
ponds very  much  with  my  own  list.  In  former  editions  of  this  work,  I  express- 
ed an  opinion,  which  1  still  adhere  to,  that  of  two  evils,  it  is  infinitely  safer,  for 
the  mother,  to  interfere  too  soon,  than  to  procrastinate 


440 

whom  one  out  of  every  92  died,  and  one  child  out  of  every  18  was 
stillborn.  If,  however,  we  were  to  exclude  cases  of  tedious  labour, 
and  attend  to  the  rest  of  cases  of  natural  labour,  or  the  consequen- 
ces of  a  correct  and  healthy  process  of  parturition,  we  would  find 
the  proportion  of  deaths  to  be  altogether  trifling  :  I  am  willing  how- 
ever to  adopt  this  average.  Let  us  now  see  the  result  of  tedious 
labour. 

In  women,  who  were  in  labour  of  their  first  child  from  between 
30  to  40  hours,  one  in  34  died,  and  one  child  in  5  was  stillborn. 
Here  then  is  a  prodigious  difference,  between  even  the  average  re- 
sult of  all  labour,  good  and  bad,  and  a  protracted  labour.  During 
the  same  period  of  labour,  amongst  women  who  had  previously 
borne  children,  and  therefore,  if  requiring  instruments,  might  be 
supposed  to  have  a  more  permanent  obstacle  or  contracted  pelvis, 
though  this  is  not  stated,  about  one  in  every  1 1  died,  and  one  child 
in  every  6  was  stillborn. 

When  labour  was  protracted  between  40  and  50  hours,  in  wo- 
men who  had  not  previously  borne  children,  one  in  13  died,  and  the 
proportion  of  stillborn  children  was  as  one  in  3£. 

If  labour  were  protracted  other  ten  hours,  that  is,  between  50 
and  60,  one-eleventh  of  the  women'died,  and  when  we  proceed  to 
the  period  of  between  GO  and  70  hours,  one-eighth  died,  and 
nearly  one-half  of  the  children.  It  is  observable,  however,  that 
only  one-twelfth  died  in  the  next  ten  hours,  but  tliis  variation  must 
arise  from  accidental  circumstances. 

It  is  impossible  to  give  any  comparison  of  these  results,  with 
those  afforded  in  the  same  hospital  by  the  use  of  instruments,  for 
artificial  aid,  it  is  evident,  was  always  long  delayed,  unless  in  cases 
where  dangerous  symptoms  not  essential  to  labour  occurred.  In- 
struments were  used,  on  account  of  tedious  labour,  in  44  cases,  and 
of  these  18  died. 

Now,  taking  the  proportion  of  deaths  in  the  parturient  state,  to 
be,  including  all  disasters  whatever,  as  1  in  92,  it  is  most  important 
to  observe  the  progressive  fatality  arising  from  delay.  Suffering 
above  30  hours  destroys  one  in  34 ;  in  other  10  hours  the  danger 
more  than  doubles,  for  1  in  13  dies;  then  1  in  11,  and  next  1  in 
8,  to  say  nothing  of  the  children. 


441 

To  deliver  a  system  of  rules  precisely  applicable  to  every  case, 
is  quite  impossible,  for  much  must  be  left  to  the  judgment  of  the 
practitioner,  who  is  to  be  guided  by  general  principles.  I  can 
therefore  only  offer  for  his  consideration,  the  following  observations. 

First,  It  is  important  in  every  case  of  parturition,  but  more  es- 
pecially if  there  be  reason  to  anticipate  a  tedious  labour,  to  prevent 
the  first  stage  from  being  protracted.  Whenever  the  uterus  is  in  a 
state  of  unsuspended  action,  that  is  to  say,  the  pains  decidedly  par- 
turient, and  continuing  without  long  intervals,  but  producing  a  slow 
effect  on  the  os  uteri,  the  means  formerly  pointed  out  for  effecting 
its  dilatation,  within  a  limited  time,  generally  twelve  hours,  ought 
to  be  resorted  to. 

Second,  Whenever  the  os  uteri  is  completely  dilated,  but  not 
sooner,  the  forceps  can  be  applied,  if  the  case  admit  of  relief  by 
the  use  of  that  instrument.  But  the  lower  that  the  head  has  de- 
scended, the  easier  is  the  application,  with  the  exception  of  those 
instances  in  which  the  head  is  very  firmly  impacted  in  the  pelvis } 
for  in  such  it  may  be  necessary  to  press  the  head  up  a  little,  in  or- 
der to  be  able  to  introduce  the  blades. 

Third,  It  is  ascertained  that  the  head,  at  the  full  time,  cannot} 
consistently  with  safety,  bear  to  have  its  transverse  diameter  redu- 
ced, by  pressure,  to  less  than  three  inches.  Most  forceps,  there- 
fore, are  so  constructed,  that  when  joined,  the  blades  at  their  most 
curved  part  which  is  to  contain  the  parietal  bones,  cannot  come 
nearer  to  each  other  than  three  inches.  The  pelvis  then  must,  af- 
ter making  an  allowance  for  the  soft  parts,  measure  at  least  that 
space  in  its  conjugate  diameter,  in  every  case  where  the  forceps  is 
applicable.  It  would,  in  a  smaller  pelvis,  be  dangerous,  always  dif- 
ficult, and  often  impossible,  to  introduce  the  blades,  and,  when  in- 
troduced, they  never  could  be  brought  through  it,  and  indeed  could 
only  be  locked  by  being  carried  above  the  brim.  This  fact,  then, 
fixes  the  limits  of  that  deformity,  which  permits  the  application  of 
the  forceps.  The  blades  might  doubtless  be  made  to  approach 
nearer,  and  to  squeeze  the  head  more,  but  as  the  child  would  per- 
ish, it  is  better  to  employ  another  method  safer  for  the  mother. 

Fourth,  The  forceps  are  merely  small  hands,  and  therefore, 
when  the  finger  of  the  operator  can  be  extended  over  the  side  of 

57 


442 

die  bead,  one  blade  can  be  passed  along  that  side,  in  whatever  part 
the  head  is  situated.  This,  it  is  indisputable,  may  be  done,  when 
verv  little,  or  even  no  part  at  all.  of  it  has  entered  the  brim  of  the 
pelvis.  The  possibility,  however,  of  applying  the  corresponding 
blade,  must  depend  on  the  dimensions  of  the  conjugate  diameter ; 
and,  if  possible,  it  would  be  useless,  unless  there  were  space  to  de- 
liver a  living  child,  or  to  bring  out  the  locked  forceps  enclosing  the 
head.  We  shall  presently  see  that,  in  this  high  situation,  the  for- 
ceps cannot  be  applied  without  great  care  and  dexterity ;  and  that 
no  small  danger  attends  the  attempt. 

Fifth,  The  lower  that  the  head  has  descended,  the  more  easy 
and  the  safer  is  the  use  of  the  instrument.  In  almost  every  case 
where  the  forceps  are  beneficial,  the  head  has  so  far  entered  the 
pelvis,  as  to  have  the  ear  corresponding  to  die  inner  surface  of  the 
vis,  and  the  cranial  bones  touching  the  perineum.  Until  this 
descent  has  taken  place,  the  common  or  short  forceps  cannot  be 
employed ;  and  it  is  to  this  instrument  that  I  confine  my  remarks, 
leaving  the  use  of  the  Ions:  forceps  to  be  specially  considered. 
When  the  finger,  without  the  introduction  of  the  hand  into  the  va- 
gina, can  easily  touch  the  ear,  and  when  the  cranium  is  in  contact 
with,  although  not  protruding  the  perineum,  the  forceps  are  appli- 
cable. 

Sixth.  It  has  been  laid  down  as  a  rule,  that  the  head  should  have 
rested  on  the  perineum  for  C  hours  previous  to  the  use  of  the  for- 
ceps ;  but  this  is  quite  unsatisfactory,  for  it  may,  in  many  cases,  be 
,  allowed  to  rest  there  longer,  and  in  others,  especially  when  the 
head  is  impacted,  it  would  be  both  unnecessary,  and  dangerous,  to 
permit  it  to  remain  so  long.  It  is  confessedly  in  every  instance, 
allowing  the  labour,  whether  with  or  without  propriety,  to  be  con- 
tinued for  six  hours  after  delivery  has  become  practicable. 

Seventh,  Whenever  the  pelvis  is  ascertained  to  be  contracted. 
we  are  to  take  care  that  the  first  stage  of  labour  be  not  prolonged, 
and  the  vigour  of  the  uterus  diminished.  As  soon  as  the  head  has 
corae  within  reach  of  the  ordinary  or  short  forceps,  unless  it  be  de- 
sce.  ther,  and  the  labour  going  on  briskly,  we  ought  to  de- 

liver, and  whenever  the  head  becomes  impacted,  we  are  warranted, 
and  called  on,  to  interfere.    In  cases,  then,  where  the  pelvis  is  dis- 


443 

proportionate  to  the  head,  we  do  not  wait  any  definite  time,  and 
pay  no  regard  to  duration,  farther  than  becoming,  every  hour  that 
labour  is  prolonged,  more  solicitous  that  the  head  may  come 
within  reach  of  the  short,  and  save  the  necessity  of  using  the  long 
forceps.  The  safest  rule  is,  to  deliver  as  early  as  delivery  is 
easily  practicable;  but  it  may  even  be  necessary  to  interfere  be- 
fore the  head  has  come  within  reach  of  the  common  forceps,  and 
when  considerable  difficulty  attends  the  application  of  the  instru- 
ment. This  is  the  case  when  the  head  has  partly  entered  the 
brim,  but  has  not  for  some  hours  yielded  farther  to  the  pains;  and 
at  the  same  time  its  deformity  is  not  so  great  as  absolutely  to  re- 
quire the  crotchet. 

Eighth,  Neither  are  we  in  cases  of  arrest,  to  proceed  strictly  on 
a  rule  founded  altogether  on  time,  unless  we  vary  that  according 
to  the  strength  of  the  constitution,  and  the  actual  efforts  made  by 
the  uterus.  We  cannot  with  reference  to  the  present  question, 
consider  a  patient  to  have  been  decidedly  30  or  40  hours  in  labour, 
who  has  had  slight  pains  at  first ;  then  a  suspension  of  these  for 
a  number  of  hours,  and  again,  perhaps,  a  return  of  trifling  pains, 
with  long  intervals  scarcely  affecting  the  os  uteri.  These  can 
scarcely  be  called  the  pains  of  labour ;  and  whether  they  should 
be  checked  or  let  alone,  must  depend  on  considerations  formerly 
brought  forward.  We  date  our  time  from  the  commencement  of 
evident  and  progressive  effects  on  the  os  uteri,  and  are  also  in  part 
regulated  by  the  state  of  the  pains  in  the  second  stage.  The 
patient  may  have  the  os  uteri  fully  dilated,  and  yet  the  next  stage 
may  be  suspended  for  some  hours,  there  may  be  a  pause  in  the 
uterine  action,  occupied  in  sleep  or  passed  in  ease.  It  is  quite 
different  when  there  has,  from  the  first,  been  continued  uterine 
action,  which  has  brought  the  head  into  the  pelvis  ;  but,  whether 
from  weak  or  restrained,  or  irregular  action,  has  not  been  efficient 
for  its  expulsion.  In  this  case,  presuming  that  the  rule  has  been 
acted  on,  of  having  the  first  stage  accomplished  within  a  certain 
number  of  hours  of  actual  labour,  that  pains  producing  little  or  no 
effect  on  the  uterus  or  its  mouth  have  been  either  stopped  or  ren- 
dered efficient,  I  am  inclined  to  lay  it  down  as  a  principle,  that  the 
second  stage  should  be  accomplished  within  a  little  longer  period 


44A 

of  time,  than  was  allowed  for  the  first.  But  to  prevent  all  mis- 
take, in  a  rule  which  is  connected  with  time,  I  must  again  ex- 
pressly state  to  the  reader,  that  as  I  formerly  spoke  of  the  first 
stage  being  accomplished  within  a  certain  period  of  actual  labour, 
and  dated  from  the  commencement  not  of  mere  pain,  which  may 
not  even  have  been  truly  uterine,  but  of  pain  affecting  the  os 
uteri ;  so  the  second  stage  is  to  be  considered  also  as  a  state  of 
uterine  pain,  and  is  not  to  have  included  in  its  duration,  the  hours 
of  suspension,  which  may  have  been  passed  in  sleep  or  tranquillity. 
When  I  come  to  lay  down  a  rule  as  to  the  time  of  interference,  I 
would  say,  and  that  from  reflection  and  experience,  that  few  cases 
ought  to  be  trusted  to  nature  for  36  hours,  and  in  general  it  is  safe 
and  proper  to  interfere  within  30.  There  may  be  cases  where 
particular  symptoms  shall  justify  and  call  for  aid,  even  within  24 
hours,  and  an  impacted  head  may  demand  it  within  that  time ; 
but,  in  an  ordinary  state  of  health  and  strength,  a  mere  case  of  ar- 
rest may  be  safely  trusted  till  between  24  and  36  hours,  and  the 
point  of  interference  in  this  range  of  12  hours,  must  be  regulated 
by  the  efforts  which  have  been  made,  the  uninterrupted  con- 
tinuance of  labour,  the  obstinacy  of  irregular  action,  the  situation 
of  the  head,  or  length  of  time  it  has  remained  in  a  situation  ren- 
dering the  forceps  applicable,  and  last  of  all,  the  general  vigour  of 
the  patient.  Finally,  the  longer  that  the  first  stage  has  been  pro- 
tracted, and  the  more  painful  or  severe  that  it  has  been,  the  shorter 
should  we  wait  in  the  second,  and  vice  versa :  this  remark,  how- 
ever, is  only  applicable  to  cases  of  arrest,  and  not  of  impaction. 

The  doctrine  I  have  now  been  supporting,  rests  on  this  princi- 
ple, that  it  is  safer  to  extract  the  child  with  the  forceps,  than  to  al- 
low the  uterus  to  remain  long  in  a  state  of  action,  whether  that  be 
regular  or  spasmodic,  and  whether  it  lead  directly  to  exhaustion, 
or  ultimately  to  disease  arising  from  irritation.  If  I  have  been 
tedious  in  my  argument,  or  been  betrayed  into  repetition,  I  plead 
that  the  great  importance  of  the  question  to  society  has  led  me  to 
trespass. 

Some  patients  urge  the  adoption  of  any  means  which  can 
abridge  their  suffering,  and  are  inclined  to  submit  to  delivery  in 
Qases  where  the  practitioner  can  by  no  means  give  his  consent. 


445 

But  in  general  an  opposite  state  of  mind  prevails,  and  it  is  not  un- 
til after  much  distress  that  the  patient  is  reconciled  to  the  use  of 
instruments.  The  result  of  a  labour  is  often  uncertain  :  on  this 
account,  as  well  as  from  motives  of  humanity,  no  hint  ought,  in 
the  early  part  of  the  process,  to  be  given  of  the  probability  of  in- 
struments being  required.  But  as  their  necessity  becomes  more 
apparent,  and  the  time  of  their  application  draws  nearer,  it  will  be 
proper  to  prepare  the  mind  of  the  relations  for  what  may  be  ne- 
cessary, if  the  delivery  be  not  naturally  accomplished.  With  re- 
gard to  the  patient  herself,  we  must  proceed  according  to  her 
disposition.  If  she  be,  from  what  we  have  already  learned, 
strongly  prepossessed  against  interference,  it  will  be  necessary  to 
give  such  prudent  hints,  and  such  explanations  of  the  practice  as 
relating  to  others,  though  not  to  herself,  as  will  prepare  her  for  her 
consent.  But  if  we  can  perceive  that  she  is  disposed  to  agree 
readily  to  whatever  may  be  necessary,  nothing  ought  to  be  said  till 
very  near  the  time,  as  the  anticipation  of  evil  is  often  as  distress- 
ing as  the  enduring  of  it.  When  we  are  to  deliver,  it  is  useful  to 
explain  shortly  and  delicately  what  we  mean  to  do,  which  has  a 
great  effect  in  calming  the  mind. 

When  the  child  could  not  be  born  by  the  efforts  of  nature,  it 
was  anciently  the  practice  to  apply  strong  forceps,  which  destroy- 
ed the  child,  or  to  open  the  head,  and  pull  it  out  with  a  hook. 
To  give  the  child  a  chance  of  living,  it  was  next  proposed,  and 
soon  became  a  general  practice,  to  turn  the  child,  and  deliver  by 
the  feet,  as  thereby  much  force  could  be  exerted.  If  the  resis- 
tance were  great,  however,  death  was  invariably  the  consequence, 
nay,  in  many  instances,  the  body  was  pulled  away  from  the  head, 
which  was  left  in  utero.  This  gave  rise  to  many  inventions  for 
the  extraction  of  the  head  under  this  circumstance.  Fillets  or 
bands  of  cloth,  were  also  applied  over  the  head,  to  enable  the 
practitioner  to  pull  it  out.  These  were  preferred  by  Daventer, 
who  informs  us  at  the  same  time,  that  single  or  double  hooks  might 
also  be  employed,  and  these  sometimes  even  brought  out  a  living 
child.  1  have  been  in  possession  of  these  instruments,  which  con- 
sist of  two  blades,  like  the  forceps,  and  lock  like  them.  The 
blades  are  narrow,  and  end  in  a  hook  which  is  fixed  at  the  ear. 


446 

The  danger  of  this  instrument  arises  from  its  hook,  which  in  all 
cases  of  contracted  pelvis,  must  have  sunk  through  the  cranium. 
In  cases  of  arrest,  it  might  sometimes  only  go  through  the  integu- 
ments, and  these  are  the  cases  where  living  children  were  born. 

It  is  surprising  that  it  did  not  at  once  occur  to  practitioners,  that 
by  taking  away  the  hook,  this  danger  might  be  avoided,  and  still 
the  head  remain  fixed  between  the  blades.  It  only  illustrates, 
what  I  have  often  shown  in  my  lectures  on  surgery,  that  men  come 
frequently  within  a  single  step  of  a  great  improvement,  without 
taking  that  step,  and  often  rest  satisfied  with  imperfect  knowledge, 
and  hazardous,  if  not  almost  fatal  practice,  rather  than  exert  the 
faculties  of  reflection  and  investigation.  That  it  is  owing  to  this 
cause,  and  not  to  any  superior  degree  of  the  inventive  faculty,  in 
the  man  who  actually  does  make  the  discovery,  is  evident  from 
this,  that  no  sooner  is  the  fact  published,  that  an  improvement  has 
been  made,  man  skilful  men  discover  it,  in  spite  of  every  endeav- 
our to  conceal  it.  Dr.  Chamberlain,  in  1672,  published  a  trans- 
lation of  the  treatise  of  Mauriceau,  in  the  preface  to  which  he  men- 
tions, that  his  father,  himself,  and  his  brother,  possessed  a  secret 
by  which  they  could  deliver  women,  without  destroying  the  child, 
although  the  pelvis  were  small.  Previous  to  this  publication,  how- 
ever, he  had  gone  over  to  Paris,  in  hopes  of  selling  his  nostrum  ; 
but  rashly  boasting  that  he  could  thereby  deliver  a  woman,  whom 
Mauriceau  had  declared  could  not  be  delivered  otherwise  than  by 
the  caesarean  operation  ;  and  failing  to  effect  what  he  promised,  he 
was  obliged  to  return  with  empty  pockets  and  little  reputation. 
Next  he  went  to  Holland,  where  he  sold  at  least  part  of  his  secret 
to  Roger  Roonhuysen,  from  whom  it  passed  to  the  celebrated 
Ruysch,  as  thorough  a  quack  as  any  of  them  ;  nor  was  it  made 
public  till  1753,  when  De  Vischer  and  Van  de  Pole  purchased 
the  information,  and  divulged  it.  The  instrument  so  revealed,  is 
known  under  the  name  of  the  lever,  but  it  is  now  ascertained  that 
Chamberlain  also  employed  the  forceps.  Whether  he  only  sold 
one  half  of  his  secret  to  Roonhuysen,  or  whether  the  latter  pre- 
ferred the  lever,  or  only  made  others  acquainted  with  it,  preserv- 
ing the  forceps  to  himself,  may,  like  the  lithotomy  of  Raw,  be  im- 


447 

portant  in  the  history  of  quackery,  but  is  of  little  consequence  to 
us.  Of  late,  the  original  instruments  of  Chamberlain  have  been 
discovered,  which,  it  is  supposed,  he  had  manufactured  himself; 
one  of  them  is  a  lever,  the  other  two  are  forceps  ;  one  of  which  is 
a  little  more  improved  than  the  other.  Soon  after  this,  other 
practitioners  in  Britain  seem  to  have  devised  similar  instruments, 
which  they  also  kept  secret,  and,  perhaps,  the  first  public  descrip- 
tion is  to  be  found  by  Mr.  Butler,  in  the  Edin.  Medical  Essays, 
for  1733.  In  the  same  volume,  Chapman  is  severely  reprimand- 
ed for  concealing  the  instrument,  which  he  gives  intimation  of  in 
his  treatise.  This  fault  he  made  reparation  for  in  his  next  edition. 
Dr.  Smellie,  in  1752,  published  his  system,  containing,  amongst 
other  useful  instructions,  a  full  account  of  the  mode  of  using  the 
forceps,  the  construction  of  which  he  improved  ;  and  nearly  about 
the  same  time,  Levret,  in  Paris,  performed  a  similar  service  to 
his  countrymen.  I  do  not  conceive  it  necessary  to  detail  the  va- 
rious alterations  which  have  been  made  on  the  forceps  and  lever,* 
but  shall  proceed  to  explain  the  manner  of  applying  and  using 
those  instruments. 

I  have  long  been  of  opinion,  that,  although  practice  may  en- 
able a  man  to  use  either  the  lever  or  the  forceps  with  dexterity, 
yet  a  young  practitioner  shall  be  less  apt  to  injure  his  patient,  and 
less  likely  to  be  foiled  in  his  attempt,  with  the  latter,  than  with  the 
former;  and,  therefore,  I  give  a  decided  preference  to  the  forceps. 
It  has  been  said,  that  we  may  operate  with  the  lever  earlier  than 
with  the  forceps,  but  that  can  scarcely  be  the  case,  if  the  long  for- 

*  Plates  of  the  different  forceps  and  levers  at  present  in  use  may  be  seen  in 
Savigny's  engravings;  and  a  very  concise  account  of  all  the  different  improve- 
ments and  alterations  of  these  instruments,  from  their  discovery  to  the  present 
time,  may  be  found  hi  Mulder's  Hist.  Liter,  et  Critica  Forcipium  et  Yectium 
Obstetricorum.  1  do  not  think  it  necessary  to  describe  the  forceps,  nor  do  I  con- 
sider the  slight  variations  made  by  different  practitioners  as  of  great  importance 
A  particular  kind  of  forceps,  with  three  blades,  was  employed  by  Dr.  Leak,  but 
it  is  never  used.  M.  A  salmi  has  altered  the  forceps  somewhat,  and  I  understand, 
makes  the  junction  at  the  extremity  of  the  part  which  is  held  by  the  operator, 
and  not  at  the  union  of  the  blade  and  handle  as  we  do.  Some  have  made  one  of 
the  handles  to  screw  off,  others  to  fold  by  a  joint,  at  the  commencement  of  i).> 
blade. 


443 

ceps  be  used ;  and  next,  it  has  been  maintained,  that  the  lever 
might  be  fixed  on  the  head,  when  both  blades  of  the  forceps  could 
not  be  applied.  I  have  never  known  such  a  case,  but  I  am  not 
prepared  altogether  to  refute  the  assertion,  and  therefore  conceive 
that  the  former  instrument  may,  with  propriety,  be  in  the  posses-* 
sion  of  every  accoucheur.fcj 

When  the  lever  is  to  be  employed,  we  are  to  apply  the  extre- 
mity of  the  instrument  on  the  mastoid  process  of  the  temporal 
bone,*  or  side  of  the  occiput.  The  patient  ought  to  be  placed  on 
her  left  side,  in  the  usual  posture;  and  we  then,  with  the  fore  finger 
of  the  right  hand,  feel  for  that  ear  which  is  next  the  pubis,  and  take 
it  as  our  guide  in  passing  the  lever.  Three  directions  must  be 
particularly  attended  to.  The  first  is,  to  keep  the  point  of  the  in- 
strument, during  the  introduction  and  operation,  close  to  the  head 
of  the  child,  lest  the  bladder  or  rectum  be  injured.  The  second 
is,  that  the  concavity  of  the  instrument  be  kept  in  contact  with  the 
curvature  of  the  head,  by  which  it  will  be  much  more  easily  intro- 
duced, than  if  it  be  separated  to  an  angle  from  the  head.  It  will, 
therefore,  be  necessary  to  keep  the  handle  back  towards  the  peri- 
neum, in  the  beginning  of  the  process ;  and  it  will  be  useful,  espe- 
cially to  the  young  practitioner,  to  have  more  than  one  lever  of 
different  degrees  of  curvature,  for  he  may  sometimes  be  able  to  in- 
troduce one  which  is  very  little  bent,  when  one  more  concave  shall 
be  applied  with  difficulty.  It  is  a  general  remark,  that  within  a 
certain  range,  the  greater  the  curvature,  the  more  is  the  difficulty 
of  introducing  it,  but  the  greater  is  its  power  over  the  head.     The 

Co)  1  am  pleased  to  find  that  the  author  lias  corrected  some  opinions  too  fa- 
vourable to  the  use  of  the  lever,  advanced  in  the  former  editions  of  this  work, 
and  which  the  Editor  then  controverted  ;  and  now  repeats  his  decided  recom- 
mendation to  young  practitioners,  rarely  to  make  use  of  the  vectis  or  lever,  ex- 
cept to  rectify  malpositions  of  the  head.  He  agrees  with  Dr.  Osborn,  that  the 
*  vectis  never  ought,  because  it  never  can,  be  used  with  safety,  when  the  child's 
"  head  is  not  sufficiently  low  to  admit  the  forceps."  For  a  full  view  of  the  ques- 
tion with  respect  to  the  comparative  advantages  of  the  two  instruments,  the 
reader  is  referred  to  Dr.  Osborn's  Essays  on  the  Practice  of  Midwifery,  in  natu- 
ral and  difficult  labours. 

*  This  process  is  very  indistinct  in  the  foetus,  but  the  direction  may  still  be 
retained,  as  it  refers  to  a  well  known  spot. 


449 

third  is,  to  attend  to  the  axis  of  that  part  of  the  pelvis  in  which  the 
head  is  placed,  and  pass  the  instrument  in  that  course.  In  the  usual 
position,  the  blade  will  be  placed  behind  the  symphysis  pubis,  or  per- 
haps a  little  obliquely,  and  the  handle  will  be  directed  back  towards 
the  perineum.  As  the  blade  is  curved  at  its  extremity,  and  as,  in 
order  to  get  it  passed,  its  surface  must  be  kept  in  contact  with  the 
head,  it  will  be  requisite  to  direct  the  handle  more  or  less  back- 
ward, according  as  the  blade  is  more  or  less  curved  ;  and  when  it 
■is  introduced,  the  handle  will  be  brought  farther  forward. 

When  we  act  with  the  instrument,  we  must  not  make  any  part 
of  the  mother  a  fulcrum ;  and,  indeed,  whatever  fulcrum  be  em- 
ployed, we  ought  not  to  raise  the  handle  much,  or  suddenly,  in 
order  to  wrench  down  the  head.  Instead;  at  first,  of  raising  the 
handle  considerably,  we  rather  attempt  to  draw  down  the  head,  as 
Mr.  Gifford  did  with  the  single  blade  of  his  extractor,  using  the 
instrument  more  like  a  hook  or  tractor,  than  a  lever.  With  the 
left  hand  placed  upon  the  shank  of  the  blade,  we  press  it  firmly 
against  the  head,  which  both  prevents  it  from  slipping,  whilst  we 
draw  down  with  the  right  hand  grasping  the  handle,  and  also  serves 
as  a  defence  to  the  urethra,  should  the  handle  be  a  little  too  muck 
raised  like  a  lever.  At  first,  we  should  pull  or  act  with  the  instru- 
ment gently,  to  see  diat  it  is  well  fixed,  or  adapted  to  the  head. 
Afterwards  we  act  with  more  force,  but  not  rashly  or  unsteadily^ 
These  attempts  will  renew  the  pains  if  they  had  gone  off,  and  then 
they  ought  only  to  be  made  during  the  continuance  of  a  pain  ;  for 
every  practitioner  knows,  that  the  co-operation  of  pains  add  pro- 
digiously to  the  utility  of  the  instrument.  The  head  being  brought, 
fully  into  the  pelvis,  and  the  face  turned  into  the  hollow  of  the  sa^ 
crum,  we  must  act  in  the  direction  of  the  outlet ;  and  for  this  pur- 
pose, it  will  be  useful  to  withdraw  the  instrument,  and  apply  it 
cautiously  over  the  chin,  which,  as  less  force  is  now  necessary,  will 
not  suffer  by  the  operation.  Or  the  forceps  may  now  successfully 
be  applied,  and  should  be  used  whenever  there  is  necessity  for  a 
speedy  delivery.  Sometimes  the  natural"  pains  will,  without  any 
further  assistance,  finish  the  delivery.  We  must  be  careful  of  the 
perineum. 

58 


450 

Tiie  forceps  with  a  single  cmve,(d)  may  I  believe  be  very  safety 
and  early  employed ;  but  it  is  usual  to  prefer  those  which  have  the 
blades  curved  laterally  also.  In  this  case  they  must  be  so  intro- 
duced, that  the  convex  edge  of  the  blades  shall  be  next  the  face. 
It  is  therefore  necessary,  to  determine  which  blade  shall  be  placed 
next  the  pelvis,  before  we  begin;  and  this  we  do  by  ascertaining  to- 
which  side  the  face  lies,  by  examining  the  position  of  the  ear,  as- 
well  as  the  general  shape  of  the  presentation.  Were  the  forceps 
with  a  single  curve  employed,  it  would  be  a  matter  of  indifference 
which  blade  were  first  inserted. 

The  instrument  is  to  be  gently  heated,  by  placing  it  in  tepid  wa- 
ter, and  the  blade  first  to  be  used  is  to  be  placed  so  as  to  prevent 
mistake.  The  bladder  being  emptied,  the  patient  is  now  to  lie  on 
her  left  side,  in  the  usual  posture,  but  with  the  pelvis  near  the  edge 
of  the  bed ;  a  female  assistant  is  to  go  to  the  opposite  side,  to  al- 
low the  patient  to  bold  by  her,  if  she  wish  it ;  whilst  another  may 
be  required  to  support  and  hold  up  the  knee  and  thigh,  when  the 
second  blade  is  introducing. 

All  things  being  prepared,  and  the  head  being  supposed  to  be 
placed  in  the  same  position  as  in  natural  labour,  the  operator  gent- 
ly introduces  two  fingers  between  the  head  and  the  pelvis,  in  the 
same  way  as  he  would  do  in  an  examination  :  he  feels  for  the  ear, 

(~clj  Such  are  those  which  are  now  generally  preferred  and  employed  in  this 
city,  under  the  name  of  Haighton's  Forceps  :  by  increasing  the  breadth  of  the 
blades,  and  enlarging  the  fenestra  or  opening  in  the  blade,  which  is  to  be  ap- 
plied over  the  parietal  protuberance,  a  firmer  hold  is  obtained  in  consequence 
of  the  greater  space  of  the  cranium,  which  is  grasped  by  the  instrument.  These 
forceps  are  also  very  conveniently  portable,  which  is  no  trivial  advantage,  a3  it 
regards  practitioners  in  the  country. 

The  following  are  the  dimensions  of  Haighton's  Forceps,  as  now  made  by 
Henry  Schively,  Surgeon's  Instrument-maker,  Philadelphia. 

Inches, 

The  whole  length .        .        -        „  11^ 

Blade  from  the  angle  of  the  joint,        .-.---  6\ 

Handle  to  the  angle  of  the  joint, 5~ 

Breadth  between  the  blades  in  the  widest  part  of  the  curve,        -  3 

Breadth  of  the  blades  near  the  point,  -  1* 

Do.        of       do.         at  its  centre,        ......  2^ 

JDo-       of       do\        near  the  handles, 2£ 


461 

ihat  he  may  know  the  part  of  the  head  on  which  lie  has  his  fingers  £, 
then  taking  up  the  blade,  he  carries  the  extremity  of  it  along  the 
hollow  of  the  hand,  cautiously  and  gently,  into  the  vagina,  sliding 
it  between  the  two  fingers  and  the  head.  In  this  introduction,  but 
more  especially  in  its  passage  over  that  part  of  the  head  which  it 
first  touches,  it  is,  owing  to  the  curve  of  the  blade,  necessary  to 
have  the  handle  directed  backwards,  and  almost  parallel  with  tho 
perineum  ;  but  as  the  hlade  advances,  the  handle  will  come  more 
downward  and  forward.  The  point  of  the  blade  is  gently  to  be  in- 
sinuated between  the  head  and  the  pelvis,  with  a  slight  wriggling 
motion  ;  and  when  the  fingers  are  no  longer  useful,  in  guiding  the 
point,  they  are  to  be  so  far  withdrawn  as  not  to  occupy  room. 
When  the  extremity  gets  opposite  to  the  ear,  it  in  general  slips 
very  easily  inward ;  and  the  full  introduction  is  sometimes  suc- 
ceeded by  a  gush  of  water,  which  may  be  foetid,  and  tinged  with 
meconium,  although  the  child  be  alive.  When  the  blade  is  fully 
inserted,  the  handle  is  in  a  line  nearly  parallel  with  the  inner  sur- 
face of  the  symphysis  pubis,  but  not  always  perfectly  correspond- 
ing to  the  axis  of  the  brim  of  the  pelvis,  for  it  is  often,  as  we  shall 
soon  observe,  carried  on  a  little  too  far.  The  blade  itself  passes 
over  the  lateral  part  of  the  head,  and  a  very  little  before  the  parietal 
protuberance,  it  traverses  the  ear,  and  its  extremity  rests  on  die 
lateral  part  of  the  jaw;  or  in  some  cases  it  does  not,  particularly  if 
the  blade  be  pretty  much  curved  laterally,  extend  farther  than  about 
the  angle  of  the  jaw,  or  neighbourhood  of  the  mastoid  process.  But 
in  the  introduction,  and  application  of  the  blade,  we  do  not  nicely 
attempt  to  describe  any  given  line ;  but  are  sure,  if  we  introduce 
it  directly  behind  the  pubis,  and  fairly  over  the  ear,  onwards,  till  it 
rest,  and  the  handle  be  brought  forward,  that  it  is  in  a  right  direc- 
tion. If  we  carry  too  much  to  either  side  of  the  pelvis,  we  have 
an  insecure  and  bad  hold  of  the  head.  If  too  far  forward  on  the 
ear,  and  the  blade  traverse  a  line  nearer  the  face  than  that  described 
when  introduced  as  directed,  it  slips.  If  too  far  back,  it  presses  on 
the  bulging  part  of  the  head,  only  with  its  anterier  edge,  and  in- 
jures it;  or  holds  so  unsteadily,  that  it  slips  as  in  the  former  case. 
The  first  blade  being  applied,  it  seldom  requires  to  be  support- 
ed but  remains  sufficiently  fixed,  between  the  head  and  the  pubis"? 


452 

and  the  operator  proceeds  to  introduce  the  second,  exactly  in  a 
reversed  manner.  When  the  first  was  inserted  into  the  vagina,  its 
handle  was  placed  almost  directly  backward  ;  when  the  second  is 
inserted,  its  handle  is  directed  forwards ;  and  therefore,  at  this  time, 
the  thigh  of  the  patient  must  be  raised  from  the  other,  by  an  assis- 
tant. The  extremity  is  to  be  guided  past  the  root  of  the  first  blade, 
into  the  passage,  by  the  finger ;  and  directed,  by  it,  between  the 
perineum  and  the  head.  By  moving  the  handle  backward,  and 
carrying,  in  the  same  degree,  the  extremity  of  the  blade  up  along 
the  sacrum,  it  traverses  the  head,  in  a  line,  corresponding  to  the 
blade,  on  the  opposite  side.  It  glides  easily  between  the  head  and 
vagina,  along  the  curve  of  the  sacrum  ;  and  in  doing  so,  comes 
sometimes  very  readily  and  at  once,  to  meet  the  lock  of  the  other 
blade,  and  join  correctly.  But,  more  frequently,  it  requires  a  lit- 
tle address  to  lock  the  instrument  so,  and  it  may  be  necessary  to 
withdraw  the  one  or  the  other  a  little,  generally  the  first,  which  has 
been  pushed  too  far  on,  in  order  to  make  them  meet.  If  this  be 
not  sufficient,  it  will  generally  be  found  that  the  difficulty  arises 
from  the  blades  not  being  Gorrectly  placed  on  parallel  lines,  on  the 
opposite  sides  of  the  head,  but  the  one  a  little  nearer  the  face,  or 
occiput,  than  the  other;  so  that  when  we  attempt  to  join  them  they 
do  not  lock,  but  the  handles  cross  or  pass  each  other.  This  is 
rectified  by  moving  the  one  which  seems  wrong  placed  gently  to  a 
correct  position  ;  or,  if  this  cannot  be  done,  it  must  be  withdrawn 
and  re-introduced.  To  attempt,  by  force,  to  thrust  the  handles 
together,  to  make  them  unite,  would  give  pain  ;  and,  most  likely,  the 
instrument  would  slip,  when  we  began  to  act ;  and  if  a  young  prac- 
titioner, who  tries  the  forceps  for  the  first  time,  were  foolishly  to 
attempt  to  pull  with  the  blades,  without  locking  them,  he  would 
only  pull  them  out,  without  bringing  away  the  head.  In  joining 
the  instrument,  care  must  be  taken,  that  neither  the  nympha,  nor 
any  other  part  of  the  mother,  be  included  in  the  lock.  The  finger 
is  therefore  passed  round  the  point  of  junction,  before  the  handles 
are  pressed  together,  or  correctly  locked.  As  the  blades  are  fixed 
along  the  sides  of  the  head,  which  is  lying  in  the  axis  of  the  brim 
of  the  pelvis,  it  is  evident  that  when  they  are  joined,  the  handles 
will  be  situated  in  the  i|ame  line  or  axis,  and  therefore  wilL  be 


453 

directed  downward,  and  backward  ;  the  lock  resting  on  the  mar- 
gin of  the  perineum. 

In  this  process,  we  must  be  deliberate  and  cautious.  We  must 
never  restrict  ourselves  in  point  of  lime,  nor  promise  that  it  s||all  be 
very  speedily  accomplished.  If  we  act  otherwise,  we  shall  be  very 
apt  to  do  mischief,  or,  if  we  find  difficulty,  to  abandon  the  attempt. 
When  the  pelvis  is  so  contracted  as  to  make  it  just  practicable  to 
introduce  the  forceps  or  lever,  that  part  of  the  head  which  is  above 
tbe  pubis  sometimes  projects  a  little  over  it,  so  that  we  cannot  pas? 
the  blade  until  we  press  backward  a  little  with  the  finger,  on  that  part 
which  we  can  reach,  or  when  the  head  is  impacted,  we  may  find  it 
necessary  to  endeavour  to  raise  it  a  little,  in  absence  of  a  pain,  before 
we  can  insinuate  the  forceps,  so  far  as  to  facilitate  the  introduction 
of  the  blade.  All  attempts  to  overcome  the  resistance  by  force, 
every  trial  which  gives  much  pain,  must  be  reprobated.  But,  on 
the  other  hand,  as  long  as  his  conduct  is  gentle  and  prudent,  the 
young  practitioner  must  not  be  deterred  because  the  patient  com- 
plains, for  the  uterine  pains  are  often  excited  by  his  attempt ;  or 
some  women,  from  timidity,  complain  when  no  unusual  irritation 
is  given  to  the  parts.  Slow,  presevering,  careful  trials,  must  be 
made  ;  and  I  beg,  as  he  values  the  life  of  a  human  being,  and  his 
own  peace  of  mind,  that  he  do  not  desist,  and  have  recourse  to 
the  crotchet,  in  cases  at  all  doubtful,  until  it  has  been  well  ascer- 
tained that  neither  the  lever  nor  forceps  could  be  used. 

The  instrument  being  joined,  we  pull  it  downward,  and  move 
it  a  little,  to  ascertain  that  it  is  well  applied.  We  then  begin  to' 
extract,  taking  advantage  of  the  first  pain.  If  the  pains  still  con- 
tinue, we  pull  the  instrument  downward,  and  backward  in  the  di- 
rection of  the  axis  of  the  brim.  Then  we  move  the  handle  a  little 
forward,  toward  the  pubis ;  and  again,  after  halting  a  second, 
move  it  slowly  back  again,  still  pulling  down.  We  must  not  carry 
the  instrument  rapidly  or  strongly  forward  or  backward,  against 
the  pubis  or  perineum,  but  the  chief  direction  of  our  force  should 
be  downward,  in  the  direction  of  the  axis  of  the  brim.  The  mo- 
tion of  the  pendulum  kind  is  intended  to  facilitate  this,  but,  if  per- 
formed with  a  free,  rapid,  and  forcible  swing,  the  soft  parts  must 
.be  bruised,  and  great  pain  occasioned.     The  operation  of  extract- 


454 

mg  is  not  to  be  carried  on  rapidly,  or  without  intermission  ;  on  the 
contrary,  we  must  be  circumspect,  and  imitate  the  steps  of  nature, 
AVe  must  act  and  cease  to  act  alternately,  and  examine,  as  we  go 
on,  the  progress  we  are  making,  and  also  ascertain  that  the  instru- 
ment is  still  properly  adapted  to  the  head  ;  for  it  sometimes  slips, 
or  shifts ;  and  this  is  particularly  the  case,  if  it  have  not  been,  at 
first,  cWrectly  applied.  In  this  event,  we  must  stop  and  rectify 
the  error ;  and,  in  every  instance,  must  ascertain  that  the  head  is 
descending  along  with  the  instrument,  otherwise  the  forceps  may 
come  suddenly  away.  The  head  being  made  to  descend,  the  face, 
begins  to  turn  into  the  hollow  of  the  sacrum,  and  in  the  same  de- 
gree, the  handles  must  move  round  on  their  axis ;  and  when  the 
face  is  thrown  fully  into  the  hollow,  the  handles  must  be  turned 
more  forward  and  upward,  being  placed  in  the  axis  of  the  outlet. 
The  pendulum  kjnd  of  motion  must  now  be  very  little,  and  is  to 
be  directed  from  one  ischium  toward  another.  As  the  head  pas- 
ses out,  the  handles  turn  up  over  the  symphysis  pubis.  In  this 
stage  we  must  proceed  circumspectly,  otherwise  the  perineum 
may  be  torn.  This  is  more  apt  to  happen,  if  we  be  not  attentive 
to  the  correct  position  of  the  forceps  on  the  head.  The  blades 
are  apt  to  slip  a  little,  and  not  embrace  the  head  properly,  but 
when  it  has  descended,  and  is  just  about  to  turn,  the  blades  press 
much  on  the  perineum,  and  when  the  head  does  turn,  the  con- 
vex edge  is  apt  to  act  so  much  on  the  perineum,  as  readily  to 
tear  it. 

The  power  required  to  be  exerted  in  bringing  down  the  head, 
must  evidently  be  proportioned  to  the  resistance,  and  is  sometimes 
very  considerable.  But  much  pain  to  the  mother,  and  fatigue  to 
the  operator  are  sometimes  produced,  by  not  pulling  or  acting  in 
the  proper  direction. 

If  the  fontanelle  present,  the  blades  of  the  forceps  are  to  be 
placed  directly  over  the  ears,  with  their  extremities  a  little  more 
backward  than  in  the  natural  presentation.  If  the  lever  be  used, 
its  point  will  rest  on,  or  near,  one  of  the  mastoid  processes.  If 
;he  face  present,  the  lever  will  rest  oh  the  back  part  of  the  tem- 
poral bone,  or  on  the  occipital  bone :  the  forceps  will  have  their 


points  directed  toward  the  vertex,  but  in  face  cases,  the  lever,  npt 
being  apt  to  slip,  may  be  used  with  advantage.^ 

If  the  forceps  or  lever  be  injudiciously  introduced,  the  bladder 
or  uterus  may  be  perforated  ;  or  if  the  head  be  allowed  to  remain 
too  long  jammed  in  the  pelvis,  some  of  the  soft  parts  may  slough. 
The  under  and  posterior  part  of  the  bladder  is  apt  to  slough  off, 
leaving  the  woman  incapable  of  retaining  her  urine. (c)  This  hf 
best  prevented,  by  being  extremely  attentive  in  every  case,  espe- 
cially in  those  where  the  soft  parts  have  sufFered  much  or  long 
from  pressure,  to  evacuate  the  urine  regularly  twice  a-day,  em- 
ploying, if  necessary,  the  catheter.  The  parts  ought  also  to  be 
kept  very  clean,  and  may  be  frequently  bathed  with  decoction  of 
camomile  flowers. 

Having  offered  these  practical  directions  for  the  use  of  the  forceps, 
in  cases  where  the  head  has  descended  considerably  in  the  pelvis,  I 
am  next  to  state,  that  sometimes  it  remains  long  very  high,  or  \9 
absolutely  prevented,  by  the  contraction  of  the  brim,  from,  making 
any  great  progress.  When  it  is  altogether  above  the  brim,  or 
only  a  small  part,  after  many  pains,  has  entered,  and  the  conjugate 
diameter  is  evidently  under  three  inches,  the  forceps,  even  if  the 
blades  could  be  applied,  could  not,  when  joined,  be  brought 
through,  if  they  do  not  approach  nearer  to  each  other  than  is  com- 
patible with  the  safety  of  the  child  ;  and  therefore  the  head  must 
be  lessened.  The  blades  of  the  forceps  may  be  made  with  little 
curvature,  so  that,  when  joined,  they  shall  not  be  above  two  inches, 
and  a  half  from  each  other ;  and,  when  applied,  they  may  be,  by 
force,  brought  perhaps  to  this  proximity.  But  can  the  head  be  ex- 

(dj  We  are  obliged  here  to  dissent  from  the  respectable  authority  of  our  au- 
thor. The  forceps,  even  in  face  cases,  will  rarely  slip  if  properly  applied.  It  is 
generally  owing  to  improper  application,  not  having  first  accurately  ascertained 
the  precise  position  of  the  head,  that  we  hear  complaints  of  the  forceps  not 
keeping  a  firm  hold.  They  are  to  be  preferred  to  the  lever  even  in  the  cases 
above  alluded  to. 

fej  The  rectum  likewise,  where  it  passes  over  or  near  the  projection  of  the 
sacrum,  may,  by  long  continued  pressure  of  the  head,  have  its  life  destroyed, 
and  sloughing  take  place  into' the  vagina,  through  which  the  faeces  will  be  dis- 
charged.  These  deplorable  effects  sometimes  follow  cases  of  impaction,  or  the 
lgCkc.d  head,  where  instruments  have  not  been  used. 


456 

pected  in  general  to  bear  this  degree  of  pressure  ?  But,  if  no  sucb 
defornjity  exist,  we  may  contemplate  the  application  of  the  long 
forceps  in  a  high  situation  of  the  head.  There  are  two  causes 
which  may  keep  the  head  high.  The  first  is,  such  a  degree  of  con- 
traction of  the  brim,  as  renders  it  difficult  for  the  uterus  to  force 
the  head  so  low,  as  in  ordinary  forceps  cases,  and  dangerous  to 
wait  until  time  ascertain,  practically  and  experimentally,  the  im- 
possibility of  accomplishing  this.  The  more  yielding  parts  of  the 
cranium  have  entered,  the  scalp  probably  is  swollen,  but  all  the 
more  solid  and  resisting  part  of  the  head  is  still  above  the  brim. 
The  linger  must  be  carried  high,  to  feel  the  ear,  and  ascertain  the 
position,  and  the  common  forceps  are  too  short  to  be  applied,  as 
part  of  the  handle  would  be  buried  in  the  vagina.  The  second 
cause  is,  spasmodic  action  of  the  uterus,  complicated  with  some 
degree  of  contraction  in  the  brim,  but  not  so  much  as  to  prevent 
regular  and  efficient  action  from  forcing  down  the  head;  for  I  have 
known  this  state  occur  in  those  who  have  formerly  borne  living 
children  without  aid.  When  spasm  in  such  instances  take  place, 
and  is  not  speedily  removed,  this  very  formidable  state  may  be  met 
with;  and  so  far  from  the  head  beiug  forced  lower  hy  the  pains,  it 
is  sometimes  rather  raised  a  little  during  the  pain.  Long  delay,  in 
this  state,  is  dangerous;  and  whatever  practice  is  to  be  adopted, 
must  be  resorted  to  promptly.  Inflammation  is  a  frequent  conse- 
quence, and  may  begin  previous  to  delivery. 

It  long  ago  was,  and  still  with  many  is,  the  practice,  in  this  state, 
to  turn  the  child ;  but  the  force  required  to  pull  the  head  through 
a  contracted  pelvis,  can  scarcely  fail  to  be  fatal  to  the  child,  to  say 
nothing  of  the  difficulty  and  danger  of  turning  in  a  uterus  much 
contracted.  Lessening  the  head  implies,  to  a  certainty,  the  death 
of  the  child,  which  is  barely  possible  to  be  avoided  by  the  other 
practice ;  but  it  does  not,  in  any  degree,  endanger  the  mother.  A 
third  practice,  and  that  which  comes  before  us  now  for  considera- 
tion, is  the  application  of  long  forceps.  It  is  vain  to  propose  this, 
when  the  head  possesses  its  usual  firmness,  and  is  of  the  ordinary 
uze,  if  the  pelvis  do  not,  with  the  soft  lining,  measure  three  inches; 
for  if  this  be  not  the  case,  the  forceps,  when  joined,  could  not  be" 
brought  through  the  pelvis,  unless  they  were  so  shaped,  as  to  per- 


457 

mit  of  squeezing  the  head  to  a  degree  most  probably  incompatible 
with  life.  Can  the  blades  be  introduced  when  the  conjugate  diame- 
ter does  measure  three  inches  ?  They  certainly  may :  but  it  is  one 
thing  to  introduce  them,  and  quite  another  thing  to  apply  them 
over  corresponding  parts  of  the  head,  so  as  to  be  able  to  lock 
them,  and  obtain  a  secure  fixture.  The  blade,  at  the  pubis,  may 
be  applied  in  a  proper  direction,  but  the  projection  of  the  sacrum 
may  turn  the  other  blade  more  easily  aside  than  an  unexperienced 
man  would  suppose  ;  and  those  who  have  most  frequently  tried  it, 
will  best  know  the  difficulty  of  adjusting  the  blades.  I  have  seen 
much  want  of  dexterity  in  introducing  the  common  forceps,  and 
the  practitioner  repeatedly  baffled  by  the  instrument  slipping.  The 
application  of  the  long  forceps  requires  more  dexterity  and  expe- 
rience ;  and  as  great  danger  may  arise  from  the  fruitless  irritation 
which  is  given  in  those  unsuccessful  attempts,  which,  besides,  end 
at  last  in  the  use  of  the  perforator,  and  often  in  the  loss  of  the  mo- 
ther, I  cannot  conscientiously  advise  any  practitioner,  until  he  have 
become  well  acquainted,  practically,  with  the  application  of  the 
common,  to  attempt  the  use  of  the  long  forceps.  It  is  easy  to  say, 
let  such  a  man  send  for  another  who  has  more  dexterity.  Such  a 
person  may  not  perhaps  be  in  his  vicinity;  and  he  must,  therefore, 
act  according  to  the  best  of  his  skill ;  and  certainly  ought  not  to 
make  a  painful  and  rash  attempt  to  apply  the  long  forceps,  but  had 
better  lose  the  child,  than  destroy  both  parent  and  child.  A  sen- 
sible man  will  make  cautious,  and  possibly  successful,  attempts  to 
appiy  the  forceps,  without  danger  to  the  parent:  he  will  satisfy 
himself  whether  he  can  succeed  in  this  way.  He  will  try  early, 
and  before  the  parts  are  in  such  a  state  as  to  be  irritated  by  his 
trial ;  and  if,  after  a  well  conducted  attempt,  he  fail,  he  has  not  in- 
jured his  patient,  and  can  still  use  the  crotchet  successfully.  It  is 
not  so  with  the  man  of  inexperience,  for  too  often  his  attempts  only 
add  to  the  danger ;  and  it  is  still  worse  for  the  patient  if  two  such 
practitioners  meet ;  for  both  must  try  their  skill,  and  double  suffer- 
ing he  inflicted.  My  opinion,  then,  on  this  question,  is,  that  a  well 
instructed  practitioner  ought  to  make  a  cautious,  steady,  but  gentle 
attempt,  to  employ  the  ion2;  forceps,  when  the  crotchet  is  not  de- 
cidedly necessary  ;  but  he  ought  never  to  make  reiterated  and  irri- 

59 


458 

bating  efforts,  which  can  only  end  in  the  production  of  fatal  inflam- 
mation.* I  cannot  say  that  I  have  known  the  lever  prove  success- 
ful, when  the  forceps  failed,  although,  a  priori,  a  superiority  might 
have  been  expected,  as  only  one  blade  requires  to  be  introduced. (e) 
When  we  are  going  to  use  the  long  forceps,  in  the  ordinary  po- 
sition of  the  head,  it  may  be  sufficient  to  introduce  two  fingers,  to 
guide  the  blade;  but  sometimes  it  is  necessary,  or  useful,  to  intro- 
duce the  hand  into  the  vagina,  as  thereby  the  blade  can  be  more 
safely  and  readily  conducted  over  the  head.  The  manner  of  ap- 
plication is  the  same  as  with  the  short  forceps.  The  blades  being 
fixed,  and  locked,  we  next  pull  a  little,  and  with  gradually  increas- 
ing strength,  to  see  that  the  hold  is  secure  :  being  satisfied  of  this, 
we  endeavour  to  bring  down  the  head,  by  drawing,  as  has  formerly 
been  described,  in  the  proper  direction,  that  is^  downward  and 
backward.  If  the  head  be  of  full  size,  and  firm,  and  the  blades- 
made  to  approach  considerably  nearer  each  other,  than  three  in- 
ches, at  their  greatest  curvature,  the  handles  at  first  cannot  touch 
each  other,  nor  come  quite  in  contact,  till  so  much  pressure  have 
been  applied,  as  shall  diminish  the  size  of  the  head  sufficiently. 
This  strong  pressure  it  is  always  possible  to  employ,  but  not  al- 
ways safe  ;  and  therefore,  if  the  blades  are  made  to  approach  near 
eadi  other,  we  never  ought  to  make  more  pressure  than  is  neces- 
sary. If  it  be  often  difficult  to  extract  the  head  when  it  is  impacted, 
within  reach  of  the  short,  it  must  be  still  more  so,  to  bring  it  down 
with  the  long  forceps,  for  less  has  entered  the  brim,  and  the  re- 
sistance is  greater.  Tn  this  attempt,  it  is  not  the  child,  only,  that 
is  at  stake,  but  the  mother  is  in  jeopardy,  from  the  pressure  on  the 
soft  parts,  and  this  pressure  must,  in  spite  of  all  our  caution,  and 

*  Smellie  and  Pudecomb  first  used  the  forceps  in  this  high  situation.  Levret 
does  not  even  notice  such  a  case ;  succeeding  writers  have  held  various  opinions. 
Baudelocque  prefers  turning,  when  that  is  practicable  ;  Capuron  joins  with  him, 
when  the  conformation  of  the  pelvis  is  good  ;  but  when  it  is  a  little  contracted, 
he  prefers  the  forceps.  In  greater  degrees,  he  looks  on  the  instrument  as  mur- 
derous. Flamant  and  Gardien  prefer  it  to  turning.  Dr.  Hamilton  and  Dr.  0»i- 
ander  both  use  it.    Saxtorph  and  Plenk,  again,  positively  forbid  it. 

fej  But  when  introduced  can  it  grasp  the  head  so  as  to  act  with  any  effect  in 
bringing  it  through  the  brim  or  superior  strait  ? 


459 

all  the  time  we  can  take,  often  be  great,  but  it  never  ought  to  be 
unprofitable.  For  instance,  if  the  forceps  be  completely  closed, 
showing  that  they  cannot  be  made  less,  and  if,  by  the  finger,  we  find 
that  the  blades  are  in  a  manner  jammed  in  the  conjugate  diameter, 
and  that  the  most  curved  part  has  not  yet  passed,  is  it  not  evident, 
that  farther  attempts  must  be  fruitless,  and  inexpressibly  dangerous? 
Is  it  not  physically  impossible,  indeed,  to  deliver,  unless  the  pelvis 
give  way,  or  the  blades  be  not  tempered  but  yield,  and  come  clo- 
ser together?  This  danger  may  be  avoided,  it  may  be  replied,  by 
diminishing  the  curve,  or  distance  of  the  blades.  True  :  it  is  pos- 
sible to  crush  the  head,  into  a  very  small  size  ;  but  is  it  not  better, 
as  this  must  destroy  the  child,  to  open  the  head,  and  deliver  with 
safety  at  least  to  the  mother. 

ORDER  2.  CASES  REQUIRING  THE  CROTCHET. 

It  unfortunately  happens,  that  sometimes  the  pelvis  is  so  greatly 
deformed,  as  not  to  permit  the  bead  to  pass,  until  it  have  been  les- 
sened by  being  opened. 

It  is  universally  agreed,  that  a  living  child  at  the  full  time  can- 
not pass  through  a  pelvis  whose  conjugate  diameter  is  only  two  in- 
ches and  a  half.  It  has  been  even  stated,  by  high  authority,  that  if 
the  dimensions  were  "  certainly  under  three  inches,  a  living  child 
could  not  be  born."  This  opinion  is  generally  correct,  and  the 
few  exceptions  depend  on  the  original  size  and  peculiar  constitu- 
tion of  the  child  ;  together  with  the  pliability  of  the  cranium,  or  the 
peculiar  shape  of  the  pelvis ;  and  the  force  and  activity  of  the  ute- 
rus, as  well  as  the  general  strength  of  the  woman.  There  have 
been  instances,  where,  even  by  the  efforts  of  nature,  living  children 
have  been  expelled  through  a  pelvis  measuring  only  three  inches; 
and  there  are  similar  examples  of  the  delivery  being,  under  the 
same  conformation,  accomplished  by  instrumental  aid.*     Every 

*  M.  Baudelocque  relates  a  mo9t  interesting  case,  where  there  were  decided 
marks  of  the  foetus  being  dead  in  utero,  and  yet  these  were  delusive;  for,  by  the 
forceps,  the  woman  was  delivered  of  a  living  child,  although  the  pelvis  measured 
only  about  three  inches.    L'Art  des  Accouch.  last  edition,  sect-  1917". — Cases  in 


460 

one  knows,  that,  even  at  the  full  time,  the  child  is  sometimes  very 
small ;  or  the  head,  when  not  very  diminutive,  may  be  extremely 
pliant.  But  in  making  up  our  judgment  in  a  case  of  deformity,  we 
are  not  justified  in  calculating  on  the  happy  coincidence  of  such  a 
state  ;  but  ought,  unless  the  finger  can  inform  us  to  the  contrary,  to 
reason  on  the  ordinary  size  and  firmness  of  the  cranium.  We  are 
not  warranted,  therefore,  instantly  to  open  the  head,  merely  be- 
cause we  estimate  that  the  pelvis  does  not,  in  its  conjugate  diame- 
ter, measure  fully  three  inches ;  but  because  we  have  ascertained, 
by  a  sufficient  but  not  a  dangerous  trial,  that  the  uterine  action  can- 
not force  down  the  head,  so  that  the  forceps  or  vectis  may  be  ap- 
plied or  acted  with  effectively.  In  all  cases  where  the  dimensions 
and  circumstances  of  the  case  are  barely  such,  as  to  warrant  a  be- 
lief that  the  head  must  be  opened,  an  attempt  ought  previously  to 
be  made,  not  in  a  careless  or  hasty,  far  less  in  a  dangerous  manner, 
but  deliberately  and  attentively,  to  introduce  and  act  with  the  vec- 
tis or  forceps. 

We  may,  however,  if  the  dimensions  be  much  under  three 
inches,  be  assured,  that  delivery  cannot  be  accomplished  without 
the  destruction  of  the  child.  But  as  it  is  a  matter  of  great  nicety 
to  determine,  within  a  fraction  of  an  inch,  the  capacity  of  the  pel- 
vis, a  practice  founded  altogether  on  arithmetical  directions  must 
be  unsafe.  In  every  case,  therefore,  we  ought  to  allow  some  time 
for  the  pains  to  produce  an  effect ;  and  this  time  should  be  longer 
or  shorter  according  as,  in  our  estimation,  the  dimensions  diminish 
below  three  inches.  When  this  is  the  case,  even  in  a  small  degree, 
we  have  no  reason  to  expect  that  the  head  can  pass,  unless  it  be 
unusually  soft  and  small,  or  burst,*  or  be  artificially  opened ;  and 
therefore  it  should,  for  the  advantage  of  the  mother,  be  perforated 
as  soon  as  the  os  uteri  is  properly  dilated ;  and  this  ought  always 

point  may  also  be  seen  in  Dr.  Alexander  Hamilton's  Letters,  pp.  94.  102.  13. — 
Similar  instances  have  come  within  my  own  knowledge. 

•  So  tar  as  I  can  judge,  the  sutures  yield  sooner  than  the  scalp,  and  the  brain 
is  effused,  or  pushed  out  like  a  bag.  When  the  integuments  open  first,  it  is 
owing,  I  apprehend,  to  sloughing  from  pressure  and  injury.  A  very  distinct  case 
of  spontaneous  bursting  of  the  cranium  may  be  found  in  Dr.  Hamilton's  Cases,  p. 
17. 


461 

to  be  effected  in,  at  the  farthest,  the  time  formerly  specified ;  but 
until  the  os  uteri  be  fully  opened,  no  attempt  to  introduce  the  per- 
forator can  be  sanctioned.  One  circumstance,  however,  must  be 
attended  to  in  our  consideration,  namely,  that  the  promontory  of 
the  sacrum  may  be  directed  somewhat  obliquely,  in  which  case, 
although  the  conjugate  diameter  measured  from  that  to  the  front, 
do  not  extend  to  three  inches,  yet  toward  the  side,  the  diameter 
be  greater.  The  thickest  part  of  the  head  may  find  its  way  down 
there,  whilst  a  narrower  or  more  compressible  portion  may  pass  at 
the  smaller  part.  In  cases  at  all  doubtful,  it  is  imperative  to  wait 
for  some  time  to  ascertain  what  can  be  effected  ;  not  that  delay  is 
less  injurious  in  crotchet  than  in  forceps  cases,  but  because  inter- 
ference in  the  latter,  may  be  productive  of  much  benefit,  without 
purchasing  that  at  the  risk  of  any  mischief;  whilst  in  the  former, 
the  greater  safety,  or  abridged  suffering,  of  the  mother,  arising  from 
the  perforation,  necessarily  implies  the  destruction  of  the  child. 
Some  eminent  men  on  the  continent  seem  to  think,  that  the  long 
forceps  may  in  most  cases  supersede  the  necessity  of  the  crotchet; 
but  I  must  dissent  from  this  opinion,  and  whilst  I  endeavour  to 
prevent  the  unnecessary  loss  of  the  child,  I  cannot  place  out  of 
consideration  the  danger,  if  not  the  destruction,  of  the  mother, 
which  may  follow  from  improper  and  injudicious  delay. 

But  although  it  be  thus  laid  down  as  a  general  rule,  that  the 
pelvis  which  measures  fully  three  inches  in  its  conjugate  diameter, 
may  possibly  admit  a  living  child  to  pass,  either  by  the  application 
of  the  vectis  or  forceps,  or  still  more  rarely  by  the  efforts  of  the 
womb,  yet  it  is  nevertheless  true,  that  sometimes  the  child  must  be 
destroyed,  even  when  the  space  is  above  three  inches.  This  may 
become  necessary,  owing  to  the  great  size  of  the  child  and  firmness 
of  the  cranium,  or  a  hydrocephalic  state  of  the  head  ;*  or  the  soft 
parts  in  the  pelvis  may  swell  so  much  as  to  diminish,  in  an  increas- 
ing ratio,  the  size  of  the  pelvis,  and  effectually  to  obstruct  delivery .f 

*  I  have  seen  a  cranium  so  enlarged  with  water,  that  when  it  was  inflated 
r.fter  delivery,  so  as  to  resume  its  former  size,  it  measured  twenty-two  inches  in 
circumference. 

f  Baudelocque  l'Art.  des  Accouch.  sect.  1705. — See  also  a  case  in  point  in 
Dr.  A.  Hamilton's  Letters,  p.  83. — Every  attentive  practitioner  must,  from  his 
own  experience,  admit  the  fact. 


462 

The  parts  may  also  be  so  tender  as  to  render  even  a  common 'exa- 
mination painful,  and  to  prevent  the  application  of  the  forceps,  or 
their  effective  action,  in  a  case  merely  equivocal.  Alarming  con- 
vulsions may  likewise  induce  us  to  perforate  the  head  in  a  case  of 
deformity,  where  it  is  perhaps  possible  that  the  vectis  or  long  for- 
ceps might  succeed,  after  a  greater  delay  or  length  of  time  than  is 
compatible  with  the  safety  of  the  mother  ;  but  this  combination  of 
evils  must  be  rare.  No  practitioner,  I  believe,  in  this  city,  has  met 
with  such  a  case.  At  one  period,  however,  the  crotchet  was  em- 
ployed in  cases  of  convulsions,  where  the  vectis  or  forceps  would 
now  be  used. 

By  the  rash  and  unwarrantable  use  of  the  crotchet,  living  chil- 
dren have  been  drawn  through  the  pelvis  with  the  skull  opened, 
-and  have  survived  in  this  shocking  state  for  a  day  or  two.* 

To  prevent  all  risk  of  bringing  a  living  mutilated  child  to  the 
world,  and  to  avoid,  at  the  same  time,  killing  or  giving  pain  to  the 
child,f  even  in  those  cases  which  clearly  demanded  the  use  of  the 
perforator,  some  have  delayed  operating  until  the  child  appeared 
to  have  been  destroyed  by  the  expulsive  efforts,  or  other  causes, 
and  have  therefore  been  anxious  to  ascertain  the  signs  by  which 
fhe  death  of  the  child  might  be  known. J     It  was  sl^  more  desh> 

*  Vide  Mauriceau,  obs.  584. — La  Motte,  case  CXC. — Hamilton's  Letters,  p. 
153. — Peu  La  Pratique,  p.  346. — Crantz  de  He  Instrument.,  8tc.  sect.  38. 

f  It  has  been  disputed,  whether  the  child  in  utero  was  capable  of  sensation, 
but  both  facts  and  reasoning  are  in  favour  of  its  sensibility. 

*  The  signs  of  a  dead  child  have  been  described  to  be  a  feeling  of  weight,  or 
sensation  of  rolling  in  the  uterus,  want  of  motion  of  the  child,  pallid  countenance 
and  sunk  eye,  coldness  of  the  abdomen,  with  diminution  of  size,  flaccid  breasts 
which  contain  no  milk,  foetor  of  the  discharge  from  the  vagina,  liquor  amnii  co- 
loured apparently  w  ith  meconium,  although  the  head  presents,  puffy  feeling  of 
the  head,  want  of  firm  tumour  formed  by  the  scalp  when  the  head  is  pressed  in 
a  narrow  pelvis,  no  pulsation  in  the  cord,  &c.  Most  of  the  cases  requiring  the 
crotchet  cannot  be  benefited  by  any  marks  characterizing  the  death  of  the 
child  in  the  progress  of  gestation  ;  and  we  well  know,  that  the  child  may  die 
during  labour,  without  testifying  this  for  a  length  of  time  by  any  sensible  signs  ; 
and  that  those  enumerated  above  are  deceitful,  I  believe  every  attentive  and  un- 
prejudiced practitioner  will  join  with  me  in  maintaining.  Nothing  but  unequi- 
vocal marks  of  putrefaction  of  the  child  itself  can  make  us  certain,  and  these  can- 
not be  discovered  for  some  time.    Foetor  of  the  discharge  is  not  a  test  of  this.. 


463 

able  to  know  these,  at  a  time  when  the  forceps  were  undiscovered. 
But  the  signs  are  in  general  extremely  equivocal,  nor  is  this  much 
to  be  regretted,  for  we  do  not  operate  because  the  child  is  dead, 
but  because  it  is  impossible  for  the  woman  to  be  otherwise  deliv- 
ered. 

The  steps  of  the  operation  are  very  simple  :  the  rectum,  but  es- 
pecially the  bladder,  being  properly  emptied,  we  place  the  fore- 
finger of  one  hand  on  the  head  of  the  child,  and  with  the  other 
hand  convey  the  perforator  to  the  spot  on  which  the  fingers  rest. 
The  instrument,  being  carried  cautiously  along  the  finger  as  a  di- 
rector, can  neither  injure  the  vagina  nor  os  uteri,  and  in  general 
no  difficulty  is  met  with  in  this  part  of  the  operation.  Sometimes, 
however,  in  very  great  deformity,  the  os  uteri  is  placed  so  oblique- 
ly, that  it  must  previously  be  gently  brought  into  the  most  favour- 
able, that  is,  the  widest  part  of  the  pelvis  ;  and  afterwards,  the 
perforator,  being  placed  on  the  head,  must  have  its  handle  in  the 
axis  of  the  brim,  which  may  require  the  perineum  to  be  stretched 
back.  These  points  being  attended  to,  the  scalp  is  then  to  be 
pierced,  and  the  point  of  the  instrument  rests  on  the  bone,  through 
which  it  directly,  or  after  a  momentary  pause,  is  to  be  pushed,  ei- 
ther by  a  steady  thrust,  or  a  boring  motion. (f)  It  is  to  be  carried 
on,  till  checked  by  the  stops.  The  blades  are  then  to  be  opened, 
so  as  to  tear  up  the  cranium  ;  and  in  order  to  enlarge  the  opening, 
they  may  be  closed  and  turned  at  right  angles  to  their  former  po- 
sition, and  again  opened,  so  as  to  make  a  crucial  aperture.  If  the 
liquor  amnii  have  been  well  evacuated,  and  a  portion  of  the  cra- 
nium have  entered  the  pelvis,  the  perforation  can  be  made  without 
any  assistance  ;  but  if  the  whole  of  the  head  be  above  the  brim. 

Vide  Mauriceau.  Obs.  281.  When  a  woman  bears  a  child  which  has  been  fot 
some  time  dead,  we  must  watch  lest  her  recovery  prove  bad. 

I  may  notice  here,  that,  in  order  to  get  rid  of  the  crotchet,  small  forceps  have 
been  applied  over  the  collapsed  head,  or  a  kind  of  crutch  or  tire-te"te  has  been 
inserted  within  the  cranium.  Some  have  employed  a  trephine  in  place  of  a 
perforator.  . 

(/)  Where  one  of  the  sutures  or  fontanelles  can  be  conveniently  reached, 
the  operation  is  facilitated  by  perforating  through  these,  as  must  ocarr  to  every 
one, 


464 

it  may  be  necessary  to  have  it  kept  steady,  by  pressure  above  the 
pubis.  It  may  be  proper  to  add,  that  if  the  face  present,  we  must 
perforate  the  forehead,  just  above  the  nose.  If  we  have  turned 
the  child,  and  wish  to  open  the  head,  the  instrument  must  be  in- 
troduced behind  the  ear. 

The  brain  is  next  to  be  broken  down,  by  turning  the  perforator 
round  within  the  head.  If  part  of  the  cranium  have  entered  the 
pelvis,  some  of  the  brain  will  come  out  with  a  squirt,  whenever  the 
bones  are  opened;  and  at  all  times  we  have  more  or  less  hemorr- 
hage from  the  vessels  of  the  brain.  Sometimes  the  blood  flows 
very  copiously.  We  have  been  advised  always  to  delay  a  consi- 
derable time  after  opening  the  head  before  we  apply  the  crotchet, 
and  doubtless,  if  the  perforation  have  been  made  early,  we  may- 
leave  the  case  for  a  little  to  the  operation  of  the  uterine  efforts, 
which,  although  they  may  not  effect  delivery,  yet  may  force  the 
yielding  head  down,  and  render  the  action  of  the  crotchet  less  se- 
vere. But  when  the  labour  has  been  already  long  protracted,  the 
propriety  of  this  direction  is  to  be  disputed,  on  grounds  I  have  for- 
merly explained,  relating  to  instrumental  aid.  If  there  be  reason 
to  believe  that  the  crotchet  can  at  once  be  easily  used,  what  ad- 
vantage is  there  in  delay  ?  In  greater  deformity  there  may,  on  the 
other  hand,  be  advantage  in  delaying  for  some  time.  Dr.  Osborn, 
in  his  Essays,  advises,  that  the  head  should  be  opened  early,  and 
that  we  should  then  delay  to  extract  for  thirty  hours.  In  cases  of 
deformity,  decidedly  requiring  the  use  of  the  crotchet,  the  first  di- 
rection is  important;  but  the  delay  of  the  specific  number  of  thirty 
hours  is,  in  most  cases,  if  not  in  every  instance,  much  too  long ; 
and  I  question  if  it  be  sufficient  to  produce,  in  any  case  where  the 
child  was  alive  when  the  skull  was  perforated,  such  a  degree  of 
putrefaction  as  materially  to  facilitate  the  operation.  The  chief 
benefit  of  delay,  is  to  bring  as  much  of  the  cranium  as  possible  into 
the  pelvis. 

If  the  deformity  have  been  no  more  than  just  sufficient  to  require 
the  use  of  the  perforator,  then,  if  the  pains  become  strong,  it  is 
possible  for  the  head  to  be  expelled  without  further  assistance.  But 
if  the  deformity  be  greater,  or  the  pains  weak,  only  the  pliable  part 
of  the  cranium  will  descend,  and  the  face  and  basis  of  the  skull  re- 


463 

•main  above  the  brim  of  the  pelvis,  until  artificial  force  be  ift 
When  this  aid  is  required,  which  is  generally  the  case,  the  crotchet 
is  to  be  introduced  through  the  aperture  of  the  cYanlitrn^  and  fixed 
upon  the  petrous  bone,  or  such  projection  of  the  sphenoid  hone, 
or  occiput,  as  seems  to  afford  a  firm  fixture.  We  then  pull  gently, 
to  try  the  hold  of  the  instrument ;  and  this  being  found  secure,  wo 
proceed  to  extract  in  the  direction  of  the  axis  of  the  brim,  by  stea- 
dy, cautious,  and  repeated  efforts,  exerting,  however,  as  much 
strength  as  may  be  necessary  to  overcome  the  difficulty.  In  doing 
this,  we  must  always  keep  a  hand,  or  some  of  the  fingers,  in  the 
vagina  and  on  the  cranium,  to  save  the  soft  parts,  should  the  instru- 
ment slip.  If  the  force  be  steadily  and  cautiously  exerted,  we  may 
always  feel  the  instrument  slipping  or  tearing  ihe  bone,  and  have 
warning  before  it  comes  away.  We  should,  in  extracting,  co -ope- 
rate as  much  as  possible  with  the  pains.  Sometimes  an  extractor, 
in  the  form  of  pincers  is  used  in  place  of  the  crotchet,  or  different 
tira-tctcs  have  been  proposed. 

But  it  may  happen,  that  the  pelvis  is  so  small,  as  to  require  the 
head  to  be  broken  down,  and  nothing  left  but  the  face  and  base  of 
the  skull.  This  is  an  operation  which  will  be  facilitated  by  the 
softening  of  the  head,  which  takes  place  som-e  time  after  death, 
rather  by  pressure  than  putrefaction.  If  the  child  be  recently  dead, 
the  bones  adhere  pretty  firmly;  and,  in  a  contracted  space,  it  will 
require  some  management  to  bring  them  away.  But  if  the  parts 
have  become  somewhat  putrid,  or  been  much  squeezed,  or  the 
child  have  been  dead,  before  labour  began,  the  parietal  and  squa- 
mous bones  come  easily  away,  and  the  frontal  bones  separate  from 
the  face,  bringing  their  orbitary  processes  with  them.  We  have 
then  only  the  face  and  basis  of  the  skull  left,  and  if  the  pelvis  will 
allow  these  remains  to  pass,  then  the  crotchet  can  be  used.  I  have 
carefully  measured  these  parts,  placed  in  different  ways,  and  en- 
tirely agree  with  Dr.  Hull,  a  practitioner  of  great  judgment  ancf 
ability,  that  the  smallest  diameter  offered,  is  that  which  extends  from- 
the  root  of  the  nose  to  the  chin.  For,  in  my  experiments,  after 
the  frontal  bones  were  completely  removed,  this  did  not  in  general 
exceed  an  inch  and  a  half.  It  is  therefore  of  great  advantage,  to 
convert  the  c.as^e  into  a  face  presentation,  with  the  root  of  the  nose 

GO 


466 

directed  to  the  pubis.  The  size  of  the  crotchet,  which  ought  to  he 
passed  over  the  root  of  the  nose,  and  fixed  on  the  sphenoid  bone, 
must,  however,  be  added  to  this  measurement.  I  never  have  yet 
been  so  unfortunate  as  to  meet  with  wiiat  may  be  considered  as 
the  smallest  pelvis,  admitting  of  delivery  per  vias  naturahs  ;*  but 
I  would  conclude,  that  whenever  the  pelvis,  with  the  soft  parts, 
measures  fully  an  inch  and  three-quarters,f  or,  if  the  head  be  un- 
usually small,  the  child  hot  being  at  the  full  time,  an  inch  and  % 
half,  the  crotchet  may  be  employed,  provided  the  lateral  diameter 
of  the  aperture  in  the  pelvis  be  three  inches,  or  within  a  fraction  of 
that,  perhaps  two  inches  and  three-quarters,  if  the  head  be  small 
or  very  soft :  and  the  operation  will  be  easy,  as  we  extend  the  dia- 
meter of  the  pelvis  beyond  what  may  be  considered  as  the  mini- 
mum. It  is  scarcely  necessary  to  add,  that  if  the  outlet  be  much 
contracted,  it  will  make  the  case  more  unfavourable  ;  and  where 
we  have  any  hesitation,  owing  to  the  shape  and  dimensions  of  the 
brim,  will  determine  us  against  this  operation.  It  ought  not  to  be 
forgotten,  that  it  is  one  thing  to  extract,  and  another  to  extract  safe- 
ly in  extreme  deformity.  Gardien  mentions,  that  Boyer,  and  other 
judicious  practitioners,  had  witnessed  repeatedly,  the  mutilation 
and  extraction  of  the  child  by  eminent  men,  but  the  mother 
sunk  immediately.  In  two  of  these  cases  the  uterus  was  rup- 
tured. 

In  this  manner  of  operating,  the  face  is  drawn  down  first,  and 
the  back  part  of  the  occipital  bone  is  thrown  flat  upon  the  neck 
like  a  tippet.  If  we  reverse  this  procedure,  and  bring  the  occiput 
first,  and  the  /ace  last,  fixing  the  instrument  in  the  foramen  mag- 
num, then,  as  we  have  the  chin  thrown  down  on  the  throat,  we 
must  have  both  the  neck  and  face  passing  at  once,  or  a  body  equal 
to  two  inches  and  three  quarters.     If  on  the  other  hand,  we  fix 


*  I  cannot  learn  that  any  case  of  extreme  deformity  in  a  pregnant  woman, 
such  as  to  render  it  barely  possible  to  deliver  with  the  crotchet,  or  necessaiy  to 
have  recourse  to  the  exsarean  operation,  has  occurred  in  this  city,  [Glasgow] 
since  the  year  1775,  when  Mr.  Whyte  performed  the  latter  operation. 

|  M.  Baudelocque  considers  the  crotchet  as  inadmissible,  when  the  pelvis  mea 
•urea  only  an  inch  and  two  thirds. 


4Q7 

mo  instrument  on  the  petrous  bone,  which  is  ceilainly  preferable 
to  the  foramen  magnum,  and,  bring  the  head  sideways,  we  must 
have  both  that  bone  and  the  vertebrae  passing  at  once,  or  a  sub- 
stance equal  to  two  inches  and  a  half  in  diameter;  and  if  the  head 
pass  more  obliquely,  then  it  is  evident  that  the  size  must  be  a  little 
more.  Although,  therefore,  Dr.  Osborn  be  correct,  in  saying, 
that  the  base  of  the  cranium,  turned  sideways,  does  not  measure 
more  than  an  inch  and  a  half;  yet  we  must  not  forget,  that  when 
the  opposite  side  comes  to  pass,  the  neck  passes  with  it,  which  in- 
creases the  size. 

The  head  being  brought  down  and  delivered,  we  then  fix  a 
cloth  about  it,  and  pull  the  body  through ;  or,  if  this  cannot  be 
done,  we  open  the  thorax,  and  fix  the  crotchet  on  it,  endeavour- 
ing to  bring  down  first  a  shoulder,  and  then  the  arm. 

In  operating  with  the  crotchet,  we  must  always  bring  the  head 
through  the  widest  part  of  the  pelvis  ;  but  where  the  deformity 
is  considerable,  no  small  force  is  requisite.  This  is  produc- 
tive of  pain  during  the  operation,  and  of  danger  of  inflammation 
afterwards,  which  may  end  in  the  destruction  of  some  of  the  soft 
parts;  or,  affecting  the  peritoneum,  it  may  prove  fatal  to  the 
patient.  From  injury  done  to  the  bladder,  retention  of  urine  may 
be  produced,  which,  if  neglected,  is  attended  with  great  risk. 
Incontinence  of  urine  is  less  to  be  dreaded,  as  it  is  sometimes 
cured  by  time.  Severe  pain  in  the  loins  and  about  the  hips,  with 
lameness,  is  another  troublesome  consequence.  If  the  patient  be 
not  affected  with  malacosteon,  the  warm,  and  at  a  more  advanced 
period,  the  cold  bath,  friction,  and  time,  generally  prove  success-^ 
ful.  Much  advantage  is  also  derived  in  this  kind  of  pain,  from 
applying  a  compress  on  the  sacro-sciatic  notch,  and  binding  it  on 
with  a  roller,  wound  firmly  round  the  pelvis,  and  all  the  upper  part 
of  the  thigh. 

In  considering  the  necessity  of  using  the  crotchet,  I  have  not, 
more  than  in  the  observations  on  the  forceps,  made  any  special 
remarks  on  those  instances,  where  the  capacity  of  the  pelvis  is 
diminished  by  an  enlarged  ovarium,  or  other  tumours,  as  the  prac- 
tice is  the  same,  or  when  a  different  course  is  proper,  that  has  be^ri 
pointed  out  in  the  commencement  of  this  work. 


To  avoid  the  destruction  of  the  child,  and  the  severity  oi  the 
operation  of  extracting  it,  the  induction  of  premature  labour  has 
been  proposed;*  and  the  practice  is  defensible,  on  the  principle 
of  utility  as  well  as  of  safety.  We  know  that  the  head  of  a  child, 
in  the  beginning  of  the  seventh  month,  does  not  measure  more 
than  two  inches  and  a  half  in  its  lateral  diameter ;  two  and  three 
quarters  in  the  end  of  that  month ;  and  three  in  the  eighth  month. 
We  know  further,  that  there  is  no  reason  to  expect  that  a  full 
grown  foetus  can  be  expelled  alive,  and  very  seldom,  even  after  a 
severe  labour,  dead,  through  a  pelvis  whose  dimensions  are  under 
three  inches  ;  and  lastly,  we  have  many  instances  where  children 
born  in  the  seventh  month  have  lived  to  old  age.  Whenever,  then, 
we  have,  by  former  experience,  ascertained  beyond  a  doubt,  that 
the  head,  at  the  full  time,  must  be  perforated,  it  is  no  longer  a 
matter  of  choice,  whether,  in  succeeding  pregnancies,  premature 
labour  ought  to  be  induced. (g)  It  is  certainly  easier  for  the  mother 
than  the  application  of  the  crotchet,  and  no  man  can  say  that  it  is 
worse  for  the  child.f     All  the  principles  of  morality,  as  well  as  of 

*  This  practice  was  first  adopted  about  the  middle  of  the  last  century,  by  Dr. 
Macauly  in  London,  and  was  afterwards  followed  out  by  others.  About  twenty 
years  after  this,  it  was  proposed  on  the  continent  by  M.  Roussel  de  Vauzeme ; 
and  lately  Mr.  Barlow,  in  the  eighth  Vol.  of  Med.  Facts,  &c.  has  given  several 
cases  of  its  success. — See  also  Med.  and  Thys.  Journal,  Vols.  XIX.  XX.  and 
XXI.  It  may  not  be  improper  for  me  to  mention  as  a  caution,  that  I  have  been 
called  to  consider  the  expediency  of  evacuating  the  liquor  amnii,  where  there 
was  no  deformity  of  the  pelvis,  but  merely  a  collection  of  indurated  fxces  in  the 
rectum.  Dr.  Merriman  has  a  very  sensible  paper  on  this  subject,  in  Med.  Chir. 
Trans.  Vol.  iii.  p.  123.  where  he  states  that,  out  of  47  cases  of  premature  labour, 
induced  on  account  of  distorted  pelvis,  19  children  have  been  born  alive,  and  ca- 
pable of  sucking.  He  very  properly  advises  that,  before  puncturing  the  mem- 
branes, it  should  be  ascertained  that  the  presentation  is  natural.  If  it  be  not,  it 
may  become  so,  in  a  day  or  two. 

CgJ  The  reader  is  referred  to  a  case  of  premature  labour,  artificially  induced, 
where  the  child  lived  some  time  after  delivery,  related  in  the  Eclectic  Reper- 
tory, Vol.  I.  p.  105,  and  seq.  The  same  woman  was  afterwards  prematurely  de- 
livered of  a  child  before  the  expiration  of  the  eighth  month,  which  lived  and  did 
well. 

t  It  has  been  proposed,  by  low  diet,  to  restrain  the  growth  of  the  child,  but 
this  is  a  very  uncertain  and  precarious  practice. 


469 

science,  justify  the  operation  ;  they  do  more,  they  demand  the 
operation.  The  period  at  which  the  liquor  amnii  should  be 
evacuated  must  depend  upon  the  degree  of  deformity  ;  and  where 
that  is  very  great,  it  must  be  performed  at  a  period  so  early,  as  to 
afford  no  prospect  of  the  child  surviving :  it  must  be  done  in  this 
case  to  save  the  mother,  or  sometimes  it  may  be  requisite  to  use 
the  lever,  even  when  labour  has  been  prematurely  brought  on. 
There  are  cases,  and  these  cases  are  not  singular,  where  the  bones 
gradually  yield,  and  become  so  distorted,  as  at  last  to  prevent 
even  the  crotchet  from  being  used.  Now,  granting  a  succession 
of  pregnancies  to  take  place  in  this  situation,  it  follows,  as  a  rule 
of  conduct,  that  if  the  deformity  be  progressive,  we  should  regu- 
larly shorten  the  term  of  gestation,  exciting  abortion,  even  in  the 
third  month,  if  necessity  require  it,  and  treating  the  case  as  a  case 
of  abortion,  enjoining  strict  rest,  and  plugging  the  vagina  to  save 
blood.  Some  may  say,  Shall  we  thus,  by  exciting  abortion,  des- 
troy many  children  to  save  one  woman  ?  This  objection  is  more 
specious  than  solid.  Those  who  make  it  would  not,  in  all  proba- 
bility, scruple  to  employ  the  crotchet  frequently ;  and  where  is 
the  difference  to  the  child,  whether  it  be  destroyed  in  the  third  or 
in  the  ninth  month  ?  How  far  it  is  proper  for  women  in  these  cir- 
cumstances to  have  children,  is  not  a  point  for  our  consideration, 
nor  in  which  we  shall  be  consulted.  I  would  say,  that  it  is  not 
proper  ;  but  it  is  no  less  evident,  that  when  they  are  pregnant  we 
must  relieve  them. 

The  interval  which  elapses  between  puncturing  the  membrane, 
and  the  accession  of  labour,  varies  from  two  to  five  or  six  days.  If 
shivering  come  on  before  pain,  an  opiate  is  the  best  remedy. 


470 

CHAP.  VII. 

Of  Impracticable  Labour. 

It  may  be  urged  against  the  reasoning  in  the  conclusion  of  the 
last  chapter,  that  the  caesarean  operation  ought  to  be  performed ; 
and,  doubtless,  in  cases  of  extreme  deformity,  if  the  proper  time 
for  inducing  labour  be  neglected,  it  must  be  performed.  But  the 
danger  is  so  very  great  to  the  mother,  that  this  never  can  be  a  mat- 
ter of  choice,  but  of  necessity.  In  balancing  the  caesarean  opera- 
tion against  the  use  of  the  crotchet  or  the  induction  of  abortion,  we 
must  form  a  comparative  estimate  of  the  value  of  the  life  of  the 
mother  and  her  child.  By  most  men,  the  life  of  the  mother  has 
been  considered  as  of  the  greatest  importance,  and  therefore,  as 
the  caesarean  operation  is  full  of  danger  to  her,  no  British  practi- 
tioner will  perform  it,  when  delivery  can,  by  the  destruction  of  the 
child,  be  procured  per  vias  naturales.  As,  in  many  instances,  the 
woman  labours  under  a  disease  found  to  be  hitherto  incurable,  it 
may  be  supposed,  that  the  estimate  will  rather  be  formed  in  favour 
of  the  child.  But,  in  the  first  place,  we  cannot  always  be  certain 
that  the  child  is  alive,  and  that  the  operation  is  to  be  successful 
with  respect  to  it ;  and,  in  the  second  place,  it  ought  to  be  consi- 
dered, how  far  it  is  allowable,  in  order  to  make  an  attempt  to  save 
the  child,  to  perform  an  operation,  which,  in  the  circumstances  we 
are  now  talking  of,  must,  according  to  our  experience,  doom  the 
mother  to  a  fate,  for  which,  perhaps,  she  is  very  ill  prepared. 

There  are,  I  think,  histories  of  twenty-three  cases,  where  this 
operation  has  been  performed  in  Britain ;  out  of  these  only  one 
woman  has  been  saved,'*  but  eleven  children  have  been  preserved. 
On  the  continent,  however,  where  the  operation  is  performed  more 
frequently,  and  often  in  more  favourable  circumstances,  the  number 
of  fatal  cases  is  much  less.f    If  we  confine  our  view  to  the  success 

Vide  a  case  by  Mr.  Barlow,  in  Med.  Records  and  Researches,  p.  154. 
7  According  to  Dr.  Hull,  we  had,  when  he  published,  at  home  and  abroad,  re- 
cords of  231  cases  of  this  operation,  139  of  which  proved  successful, — Vide 
Translation  of  M.  Bandelocque's  Memoir,  p.  233. 


471 

of  the  operation  in  this  island,  [Great  Britain]  we  must  consider  \i 
as  almost  uniformly  fatal  to  the  mother.  This  mortality  is  owing, 
not  only  to  the  injury  done  to  the  cavity  of  the  ahdomen,  and  the 
consequent  risk  of  inflammation,  even  under  the  most  favourable- 
circumstances,  and  with  the  best  management;  but  also  to  the  mor- 
bid condition  of  the  system,  at  the  time  when  the  operation  was 
performed,  many  of  the  women  being  affected  with  malacosteon^ 
which  would  in  no  very  long  time  have  of  itself  proved  fatal.  These 
dangers  have,  probably,  sometimes  been  increased  by  delaying  the 
operation,  until  much  irritation  had  been  excited.  From  this  un- 
favourable view,  it  may  perhaps  arise  as  a  question,  whether  nature, 
if  not  interfered  with,  might  not,  as  in  extra-uterine  pregnancy,  re- 
move by  abscess  the  child  from  the  uterus?  It  has  been  said,  that 
this  event  has  taken  place ;  but  I  do  not  recollect  one  satisfactory 
.case  upon  record.  Whenever  this  has  happened,  the  uterus  has 
either  been  ruptured,  and  the  child  expelled  into  the  cavity  of  the 
abdomen ;  or,  in  a  very  great  majority  of  the  instances,  the  child 
has,  evidently  from  the  first,  been  extra-uterine.  We  are  therefore 
led  to  conclude,  that  the  mother  who  cannot  be  delivered  by  the^ 
crotchet,  must  submit  to  the  caesarean  operation,  or  must  inevitably 
perish,  together  with  the  fruit  of  her  womb. 

It  has  been  asserted  by  Dr.  Osborn,  that  this  operation  can  sel- 
dom if  ever  be  necessary ;  never  where  there  is  the  space  of  an 
inch  and  a  half  from  pubis  to  sacrum,  or  on  either  side  :  and  that 
he  himself  has,  in  a  case  where  the  widest  side  of  the  pelvis  was 
only  an  inch  and  three  quarters  broad,  and  not  more  than  two 
inches  long,  delivered  the  woman,  by  breaking  down  the  cranium, 
and  turning  the  basis  of  the  skull  sideways.  As  the  patient  reco- 
vered, and  afterwards,  I  think,  died  in  the  country,  where  she 
could  not  be  examined,  we  cannot  say  to  a  certainty  what  the  di- 
mensions of  the  pelvis  were.  Dr.  Osborn  must  only  speak  accord- 
ing to  the  best  of  his  judgment.  I  have  the  highest  respect  for  his 
character  and  for  his  works,  and  nothing  but  irresistible  arguments 
could  make  me  doubt  his  accuracy.  But  from  the  statement  which 
I  have  already  given  of  the  dimensions  of  the  head,  when  bro- 
ken down  at  full  time,  as  well  as  from  the  experiments  of  Dr.  Hull, 
and  the  arguments  ef  Dr.  Alexander  Hamilton  and  Dr.  Johnson,  I 


472 

am  convinced  that  there  must  be  some  mistake  in  Sherwood's  case. 
Had  the  child  been  brought  by  the  face,  there  might  have  been 
room  for  it  to  pass,  so  far  as  the  short  diameter  of  the  passage  is 
concerned ;  but  the  lateral  diameter  is  too  small  for  the  head,  if  of 
the  usual  size,  to  pass,  in  that  which  I  consider  as  the  most  favour- 
able position.  In  the  cases  related  by  Dr.  Clarke,*  who  was  a 
practitioner  of  the  highest  authority,  we  are  informed,  that  the 
short  diameter  of  the  passage  did  not  exceed  an  inch  and  a  half, 
but  we  are  not  informed  of  the  lateral  extent.  As  the  women  both 
recovered,  the  precise  dimensions  and  construction  of  the  pelvis 
cannot  be  determined.  It  is  likewise  much  to  be  regretted,  that 
the  diameter  of  the  cranium,  or  cranium  and  neck,  in  the  state  in 
which  they  may  have  been  supposed  to  come  through  the  passage, 
was  not  taken  after  delivery.  Where,  and  only  where,  it  can  be 
ascertained,  that  the  head  placed  in  the  position  in  which  it  was 
drawn  through  the  pelvis,  does  not  form,  in  any  part,  a  substance 
measuring  more  than  an  inch  and  a  half  by  two  inches  or  three 
inches,  it  is  allowable  to  infer,  that  the  cavity  through  which  it 
passed  may  have  been  as  small  as  that. 

Finally,  this  is  a  question  on  which,  although  we  may  lay  down 
a  general  rule,  we  must  admit  of  some  exceptions;  for  a  premature, 
or  a  very  small  child,  may  be  brought  through  a  pelvis  which  will 
not  permit,  by  any  means,  an  ordinary  sized  foetus  to  pass.  But 
it  behooves  us,  in  our  reasoning,  to  judge  every  child  to  be  at  the 
full  time,  unless  we  know  the  contrary,  and  to  make  an  estimate  on 
the  average  magnitude ;  and  until  the  contrary  is  proved,  by  dis- 
section of  the  mother,  or  careful  and  rigid  measurement  of  the 
child  after  delivery,  I  must  hold  to  the  position  formerly  laid  down- 
that  the  crotchet  cannot  be  used  when  the  child  is  of  the  full  size, 
unless  we  have  a  passage  through  the  pelvis,  measuring  fully  an 
inch  and  three-quarters  in  the  short  diameter,  and  three  inches  in 
length  ;  or,  if  the  child  be  premature  and  soft,  an  inch  and  a  half 
broad,  and  two  inches  and  three-quarters  long.f     It  is  in  this  ex- 


*  Vide  Dr.  Osborn's  Essays,  p.  203,  and  London  Med.  Journal,  V1T.  p.  40. 
j- 1  believe  few  will  dispute,  that  the  precise  deformity  requiring'  the  cesa- 
rean operation,  •must  to  a  certain  extent,  be  modified  by  the  dexterity  of  {lie* 


473 

treme  deformity  even  questionable  whether  extraction  be  not  as 
dangerous  as  the  caesarean  operation,  and  we  always  ought  to  con- 
sider well,  before  we  give  the  preference  to  mutilation,  in  such 
cases. 

The  operation  itself,  although  dangerous  in  its  consequences, 
and  formidable  in  its  appearance,  is  by  no  means  difficult  to  per- 
form. Some  advise  the  incision  to  be  made  perpendicularly  in 
the  linea  alba,(AJ  others  transversely,  in  the  direction  of  the  fibres  of 
the  transversalis  muscle.  Perhaps  the  precise  situation  and  direc- 
tion of  the  wound  must  be  regulated  by  the  circumstances  of  the 
case,  and  the  shape  of  the  abdomen ;  but  in  general,  I  apprehend, 
that  the  transverse  wound  will  be  most  eligible.  The  length  of 
the  incision,  through  the  skin  and  muscles,  ought  to  be  about  six 
inches  ;  and  if  a  vessel  bleed,  so  as  to  require  the  ligature,  it  will 
be  proper  to  take  it  up  before  proceeding  further.  The  uterus  is 
next  to  be  opened  by  a  corresponding  incision ;  and  as  the  fun- 
dus, owing  to  the  pendulous  shape  of  the  abdomen,  is  the  most 

operator.  I  shall  suppose  that  a  surgeon  in  a  remote  part  of  the  country,  far 
from  assistance,  is  called  to  a  patient,  whose  child  is  evidently  alive,  and  whose 
pelvis  measures  just  as  much  as  would  render  it  barely  possible  to  use  the 
crotchet,  were  he  dexterous ;  but  he  has  not  a  belief  that  he  could  accomplish 
the  delivery  with  that  instrument.  'Would  that  man  be  wrong  in  performing  the 
cesarean  operation  ?  In  such  a  case  I  would  say,  upon  the  principle  that  a  man 
is  to  do  the  most  good  in  his  power,  that  if  no  operator  more  experienced  can 
be  had  within  such  time  as  can  be  safely  granted,  the  surgeon  ought,  after  taking 
the  best  advice  he  can  procure,  to  perform  the  caesarean  operation,  by  which  he 
will  save  one  life  at  least.  By  the  opposite  conduct,  there  is  ground  to  fear  that 
both  would  be  lost.  In  a  case  related  in  the  Jour,  de  Med.  for  1780,  a  woman, 
in  the  village  of  Son,  had  the  child  turned,  and  even  the  limbs  separated  without 
delivery  being  accomplished  ;  four  days  afterwards,  the  cxsarean  operation  was 
performed,  and  the  woman  died.  rf  , 

(~hj  Mauriceau,  Baudelocque,  Capuron,  Solayres,  and  the  generality  of  the 
modern  French  Accoucheurs  and  Surgeons  who  have  had  the  greatest  success 
in  performing  the  Caesarean  operation,  prefer  making  the  incision  in  the  linea 
alba.  Cooper  agrees  in  recommending  tins  mode.  Vide  Diet,  of  Surgery ; 
Dorsey's  Edition,  Vol.  I.  p.  163.  Some  of  the  reasons  assigned  for  this  pre- 
ference, are  that  the  incision  is  made  with  greater  facility  and  is  less  painful, 
because  there  are  fewer  parts  to  be  divided  ;  and  the  hemorrhage  is  less  |  Tofuse. 
The  uterus  is  readily  brought  into  view,  and  it  is  cut  in  its  middle  portion,  and 
parallel  to  its  principal  fibres. 

CI 


474 

prominent  part,  the  incision  will  in  general  be  made  there,  unless 
the  external  wound  be  made  lower  than  usual.  The  child  is  next 
to  be  extracted,  and  immediately  afterward  the  placenta.  One 
assistant  is  to  take  the  management  of  the  child,  whilst  another 
takes  care  to  prevent  the  protrusion  of  the  bowels.  In  this  part  of 
the  operation,  although  pretty  large  vessels  are  divided,  yet  the 
hemorrhage  is  seldom  great :  it  has,  however,  proved  fatal.  The 
external  wound  is  now  to  be  cleansed,  its  sides  brought  together, 
and  kept  in  contact  by  a  sufficient  number  of  stitches  passed 
through  the  skin  alone,  or  the  skin  and  muscles,  avoiding  the  peri- 
toneum. Adhesive  plasters  are  to  be  placed  carefully  in  the  inter- 
vals ;  and  a  bandage  with  a  soft  compress  being  applied,  the  patient 
is  to  be  laid  to  rest.  An  anodyne  should  be  given,  to  diminish 
the  shock  to  the  system;  and  our  future  practice  must,  upon  the 
general  principles  of  surgery,  be  directed  to  the  prevention  or  re- 
moval of  abdominal  irritation  or  inflammation.  The  patient  may 
die,  although  there  be  very  little  inflammation  of  the  peritoneum. 
It  has  been  proposed  by  Dr.  Hull,  to  whose  work  I  refer  for  more 
particular  information,  to  operate  as  soon  as  the  os  uteri  is  dilated., 
and  before  the  membranes  burst,  in  order  that  the  wound  of  the 
uterus  may  contract  into  a  smaller  size. 

In  order  to  supersede  the  csesarian  operation,  and  even  to  avoid 
the  use  of  the  crotchet,  it  was  many  years  ago  proposed  to  divide 
the  symphysis  pubis,  in  expectation  of  thus  increasing  the  capaci- 
ty of  the  pelvis.  This  proposal  was  founded  on  an  opinion,  that 
the  bones  of  the  pelvis,  either  always  or  frequently  did  spontane- 
ously separate,  or  their  joinings  relax,  during  gestation  and  partu- 
rition, in  order  to  make  the  delivery  more  easy.  In  deformity  of 
the  pelvis,  the  symphysis  was  first  divided  by  a  knife  during  la- 
bour, by  M.  Sigault,  in  1777,  assisted  by  the  ingenious  M.  Al- 
phonse  Le  Roy.  The  operation  was  afterwards  repeated  on  the 
continent,  with  various  effects  according  to  the  degree  of  deformi- 
ty, and  extent  of  the  separation. (i)     It  has  only  once*  been  adopt- 

(»')  It  has  of  late  again  been  recommended,  by  some  French  writers  of  emi- 
nence ;  vide  Capuron  cours  theorique  et  pratique,  &c.  p.  673  and  seq.  Gardien 
Traits  d'Accouchemens,  Tom.  3,  p.  20,  and  seq.  and  J.  B.  De  Mangeon,  De  os- 
sium  pubis  Synchondrotomia.    Parisiis,  1811. 

*  Vide  case  by  Mr.  Whelchman,  in  London  Med.  Jour,  for  1790,  p.  46, 


475 

cd  in  this  country,  because  it  is  not  only  dangerous  in  itself  to  the 
mother,  but  also  of  limited  benefit  to  the  child.  We  have  already 
seen,  that  there  is  a  certain  degree  of  deformity  of  the  pelvis,  which 
must  prevent  a  child  at  the  full  time,  and  of  the  average  size,  from 
passing  alive,  or  with  the  head  entire.  Now,  in  a  case  where  it 
is  barely  impracticable  to  use  the  lever  or  forceps,  and  where  it 
just  becomes  necessary  to  open  the  head,  the  division  may  per- 
haps save  the  child,  and  with  less  danger  to  the  mother  than  would 
result  from  the  caesarean  operation,  which  is  the  only  other  chance 
of  saving  the  infant.  If  we  increase  the  contraction  of  the  pelvis 
beyond  this  degree,  then  the  chance  of  saving  the  child  is  greatly 
diminished  ;  and  the  extent  to  which  the  bones  must  be  separated 
to  accomplish  delivery,  would  in  all  probability  be  attended  with 
fatal  effects.  In  such  a  case,  the  crotchet  can  be  employed  with 
safety  to  the  mother,  and  continues  to  be  eligible,  until  we  find  the 
space  so  small  as  to  require  the  caesarean  operation ;  and  in  this 
case,  the  division  can  do  no  good.  It  cannot  even  make  the  crotch- 
et eligible,  owing  to  the  shape  of  the  pelvis  in  malacosteon,  and 
the  great  mischief  which  would  be  done  to  the  parts  after  the  di- 
vision, by  the  necessary  steps  of  the  instrumental  delivery.  There 
is  only  one  degree  of  disproportion,  then,  betwixt  the  head  and 
the  pelvis,  which  will  admit  of  the  division  ;  but  the  smallest  de- 
viation from  this,  destroys  the  advantage  of  the  operation.  Now, 
as  this  disproportion  is  so  nice,  we  cannot,  in  practice,  ascertain  it; 
for  although  we  could  determine,  within  a  hundredth  part  of  an 
inch,  the  capacity  of  the  pelvis,  yet  we  cannot  determine  the  pre- 
cise dimensions  of  the  head,  and  thus  establish  the  relation  of  the 
two.  On  this  account,  the  division  of  the  symphysis  pubis  can- 
not be  adopted  with  advantage,  either  to  the  mother  or  child. 


476 

CHAP.  VIII. 

Of  Complicated  Labour. 

ORDER  1.  LABOUR  COMPLICATED  WITH  UTERINE  HEMORRHAGE. 

During  labour,  there  is  always  a  slight  discharge  of  bloody 
slime,  when  the  membranes  begin  to  protrude  ;  for  the  small  ves- 
sels of  the  decidua,  near  the  cervix  uteri,  are  opened.  In  some 
cases,  a  very  considerable  quantity  of  watery  fluid,  tinged  with 
blood,  flows  from  the  womb,  but  this  is  attended  with  no  inconveni- 
ence. It  may  happen,  however,  that  pure  blood  is  discharged,  and 
that  in  no  small  quantity.  If  this  take  place  in  the  commencement 
of  labour,  it  differs  in  nothing  from  those  hemorrhages  which  I  have 
formerly  considered.  But  occasionally  the  flooding  does  not 
begin,  till  the  first  stage  of  labour  be  nearly  or  altogether  complet- 
ed. If  the  membranes  be  still  entire,  it  proceeds  certainly  from 
the  detachment  of  part  of  the  placenta  or  decidua,  and  often  i> 
connected  with  unusual  distention  of  the  uterus,  from  excessive 
quantity  of  liquor  amnii,  or  with  ossification  of  the  placenta.  If 
the  membranes  have  broken,  then  we  must  consider  the  possibi- 
lity of  its  proceeding  from  rupture  of  the  uterus,  and  must  inquire 
into  the  attending  symptoms.  Sometimes  it  will  be  found  to  pro- 
ceed from  tedious  and  exhausting  labour,  from  improper  exertion, 
or  rude  attempts  to  dilate  the  os  uteri,  or  alter  the  presentation  ; 
or  it  may  be  caused  by  rupture  of  the  umbilical  cord.  Now, 
in  this  order  of  labours,  the  practice  is  very  simple,  and  admits  of 
little  difference  of  opinion.  For  every  experienced  practitioner  must 
admit,  that  when  the  hemorrhage  is  considerable,  and  is  increas- 
ing, or  continuing,  the  only  safety  consists  in  emptying  the  uterus. 
If  the  pains  be  smart,  frequent,  and  effective,  the  labour  advancing 
regularly,  and  there  be  reason  to  suppose  that  it  will  be  finished 
before  the  hemorrhage  have  continued  so  long  as  to  produce  injuri- 
ous effects,  we  may  safely  trust  to  nature.  We  must  keep  the  pa- 
tient very  cool,  and  in  a  state  of  perfect  rest.  But  if  the  pains  be 
'weak,  ineffective,  and  rather  declining  than  increasing,  whilst  the 


477 

hemorrhage  is  rather  increasing  than  diminishing,  we  must  deliver 
the  woman,  either  by  turning  the  child,  or  applying  instruments, 
according  to  the  circumstances  of  the  case,  and  the  situation  of 
the  head.     Opiates  are  useful. 

ORDER  2.  WITH  HEMORRHAGE  FROM  OTHER  ORGANS. 

When  hemorrhage  takes  place  from  the  lungs  or  stomach  dur- 
ing parturition,  we  ought  to  have  recourse,  in  the  first  place,  to 
blood-letting,  or  such  other  means  as  we  would  employ  were  the 
patient  not  in  labour.  If  the  hemorrhage  continue  violent,  or  be 
increased  by  the  pains  of  parturition,  we  must  consider,  whether 
artificial  delivery,  or  a  continuance  of  the  natural  process,  will  be 
attended  with  least  exertion  and  irritation,  and  consequently  with 
least  danger,  and  we  must  act  accordingly.  In  general,  these  cases 
can  seldom  be  trusted  to  nature,  and  prompt  delivery  is  requisite. 
It  is  scarcely  necessary  to  add,  that  a  complication  of  labour,  with 
other  diseases  than  hemorrhage,  but  which  may  be  incurred  by  it 
to  a  dangerous  or  fatal  degree,  will  equally  justify  interference. 

ORDER  3.  WITH  SYNCOPE. 

Syncope  may  proceed  from  various  causes,  such  as  hemorrhage, 
or  rupture  of  the  uterus ;  but  these  cases  have  been  already,  or 
will  be  considered.  It  may  proceed  from  a  delicate  nervous  con- 
stitution, from  long  continued  labour,  from  particular  states  of  the 
heart  or  stomach,  and  from  passions  of  the  mind.  A  simple 
paroxysm  of  fainting,  unless  it  proceed  from  causes  which  would 
otherwise  incline  us  to  deliver,  such  as  tedious  labour,  flooding,  he. 
is  not  to  be  considered  as  a  reason  for  delivering  the  woman.  We 
are  to  employ  the  usual  remedies,  and  particularly  keep  the  person 
in  a  recumbent  posture.  Ammoniated  tincture  of  valerian,  or  tincture 
of  opium,  are  useful.  But  if  the  paroxysms  be  repeated,  whatever 
their  cause  may  be,  we  ought  to  deliver  the  woman,  if  the  state  of 
the  os  uteri  will  permit.  We  must  be  very  careful  to  prevent 
hemorrhage,  after  the  expulsion  of  the  child. 


478 


OHDER  4.  WITH  CONVULSIONS. 


Convulsions  may  occur,  either  during  pregnancy  or  labour,  and 
are  of  different  kinds,  requiring  opposite  treatment.  One  species 
is  the  consequence  of  great  exhaustion,  from  excessive  fatigue,  te- 
dious labour  or  profuse  hemorrhage.  This  makes  its  attack  with- 
out much  warning,  and  generally  alternates  with  deliquium,  or  great 
feeling  of  depression  and  debility ;  the  muscles  about  the  face  and 
chest  are  chiefly  affected,  and  the  pulse  is  small,  compressible,  and 
frequent,  the  face  pale,  the  eye  sunk,  the  extremities  cold.  The 
fits  succeed  each  other  pretty  quickly,  and  very  soon  terminate  in 
a  fatal  syncope.  This  species  naturally  requires  that  we  should, 
first  of  all,  check  the  farther  operation  of  the  exciting  cause,  by 
restraining  hemorrhage,  or  preventing  every  kind  of  exertion,  and 
then  husband  the  strength  which  remains,  or  recruit  it  by  cordials. 
Opiates  are  of  great  service.     Delivery  is  usually  necessary. 

Hysterical  convulsions  are  more  common  during  pregnancy  than 
labour,  and  have  already  been  noticed.  I  have  only  to  say  here, 
that  the  muscles  of  the  trunk  and  extremities  are  affected  to  a  great- 
er degree  than  those  of  the  face  :  there  is  an  appearance  of  glo- 
bus, often  considerable  palpitation,  and  occasionally  a  kind  of 
crowing  or  screaming  during  the  fit.  At  the  termination  of  it  there 
is  usually  wind  discharged  from  the  stomach,  and  often  as  the 
struggling  is  about  to  end,  the  bowels  seem  to  be  much  inflated, 
and  suddenly  subside.  Part  of  this,  however,  is  a  deception,  for 
the  spine  is  in  such  cases  frequently  bent  back,  so  as  to  render  the 
abdomen  apparently  more  prominent.  In  the  interval  there  is  a 
tendency  to  laugh  or  cry,  or  sometimes  a  childish  appearance. 
This  kind  of  convulsion  is  rare  in  the  parturient  state.  If  the  face 
be  flushed,  or  there  be  headach,  and  suffusion  of  the  eyes,  vene- 
section should  be  premised  ;  and  if  this  be  not  sufficient,  then  we 
give  antispasmodics.  If  on  the  other  hand  there  be  no  undue  vas- 
cular action  or  determinationno  the  head,  we  may  at  once  give  an- 
tispasmodics, such  as  tincture  of  valerian,  or  assafcetida  ;  a  smart 
clyster  is  also  of  great  service.     If  these  means  fail,  and  the  labour 


479 

be  far  advanced,  it  will  be  proper  to  employ  the  forceps,  but  in 
general  artificial  delivery  is  not  required. 

The  most  frequent  species  of  puerperal  convulsions,  however, 
is  of  the  nature  of  eclampsia,  which  occurs  a  hundred  times  for 
once  that  the  others  appear.  Convulsions  may  affect  the  patient 
suddenly  and  severely.  She  rises  to  go  to  stool,  and  falls  down 
convulsed  ;  or,  sitting  in  her  chair,  conversing  with  her  attendants, 
her  countenance  suddenly  alters,  and  she  is  seized  with  a  fit;  or, 
she  has  been  lying  in  a  sleep,  and  the  nurse  is  all  at  once  alarm- 
ed by  the  shaking  of  the  bed,  and  the  strong  agitation  of  her  pa- 
tient. Immediately  all  is  confusion  and  dismay,  and  the  screams 
of  the  females  announce  that  something  very  terrible  has  happen- 
ed. Presently  the  convulsion  ends  in  a  short  stupor,  from  which 
the  woman  awakes,  unconscious  of  having  been  ill ;  and  thus  for 
a  time,  the  apprehensions  of  the  attendants  are  calmed.  But  in  a 
short  time  the  same  scene  is  generally  repeated  ;  or,  perhaps,  al- 
though the  convulsion  have  gone  off,  the  stupor  remains ;  and  it  is 
always  more  unfavourable  when  the  patient  continues  insensible  in 
the  interval  of  the  fits.  It  is,  however,  not  unusual  for  the  fit  to  be 
preceded  by  some  symptoms,  which,  to  an  attentive  observer,  in- 
dicate its  approach.  These  may  even  exist  to  a  degree  which 
cannot  be  neglected.  They  are,  headach,  which  is  sometimes 
dreadful ;  ringing  in  the  ears  ;  dazzling  of  the  eyes,  or  appearance 
of  substances  floating  before  them,  either  opaque,  or,  more  fre- 
quently, of  a  fiery  brightness.  In  other  cases,  the  first  indication 
is  violent  pain  in  the  stomach,  with  insupportable  sickness,  for, 
sometimes,  the  stomach  is  the  first  part  which  suffers  from  irrita- 
tion of  the  origin  of  the  nerves,  and  the  patient  may  die  before  con- 
vulsions take  place.  The  pulse  usually  is  slow ;  the  patient  some- 
times sighs  deeply,  or  has  violent  rigours,  which,  in  the  second 
stage  of  labour,  are  always  hazardous.  There  is  great  drowsiness 
during  the  pains.  It  is  neither  uncommon  nor  dangerous  for  the 
woman  to  be  drowsy  between  the  pains  ;  but  here,  even  during 
them,  she  falls  into  a  deep  sleep.  When  the  attack  comes  on, 
which  very  often  is  soon  after  these  preludes  appear,  the  muscles 
are  most  violently  convulsed  ;  the  whole  frame  shakes  strongly. 


480 

and  the  face  is  dreadfully  distorted,*  and  often  swollen.  The 
tongue  is  much  agitated,  and  is  very  apt  to  be  greatly  injured  by 
the  teeth  ;  foam  issues  from  the  mouth,  and  the  convulsive  inspi- 
ration often  draws  this  in  with  a  "  hissing  noise ;"  or  she  snores 
deeply,  and  cannot  be  roused  during  the  fit.  The  skin  becomes, 
during  the  convulsion,  livid  or  purple.  The  pulse,  during  the  whole 
of  the  disease,  is  often  slow,  but  sometimes  it  does  at  last  become 
frequent,  small,  and  irregular.  This  attack  may  end  at  once  in  fa- 
tal apoplexy,  but  generally  the  patient  recovers,  and  is  quite  insen- 
sible of  having  been  ill.  There  may  be  only  one  fit ;  and  without 
any  interference,  I  have  known  the  disease  go  off,  and  no  return 
take  place  ;  but  in  general  the  attacks  are  repeated,  and  if  they  do 
not  prove  soon  fatal,  or  are  not  averted  by  art,  they  recur  with  the 
regularity  of  labour  pains,  becoming  more  and  more  frequent  as 
they  continue.  The  woman  appears  to  have  no  labour  pains,  yet 
ihe  os  uteri  is  affected,  and  sometimes  the  child  is  expelled,  or  if 
the  patient  become  sensible  in  the  intervals,  and  feel  a  pain  coming 
on,  it  appears  to  be  speedily  carried  off  by  a  supervening  convul- 
sion. The  fit  may  last  only  a  few  seconds,  or  may  continue  with 
very  little  remission  for  half  an  hour.  In  some  instances  the  patient 
is  not  sensible  of  bearing  the  child,  and  is  afterwards  long  of  recol- 
lecting her  delivery. 

Convulsions  may  occur  in  any  period  of  labour,  or  before  it  has 
begun,  or  after  the  delivery  of  the  child;  and  in  this  last  case,  are 
sometimes  preceded  by  great  sickness  or  oppression  of  the  sto- 
mach. Dr.  Leak  relates  the  case  of  a  patient  who  had  ten  or  eleven 
of  these  fits ;  the  abdomen  was  swelled  and  tense,  and  she  vomited 
phlegm  mixed  with  blood,  which  probably  came  from  the  tongue. 
She  recovered  by  means  of  blood-letting  and  clysters. 

Puerperal  convulsions  are  quite  different  from  epilepsy,  for  they 
recur  at  no  future  time,  except  perhaps  in  a  subsequent  pregnancy. 
They  take  place  in  greater  number  in  a  given  time,  than  epilepsy 
does  hi  general,  and  belong  to  the  genus  Eclampsia  of  Sauvages, 
"  artuum  vel  musculorum  plurimorum  spasmus  clonicus  acutus, 

*  Mr.  Fynney  gives  a  case,  where  the  lower  jaw  was  luxated  during  convul- 
sions, which  came  on  in  the  birth  of  a  second  child,  or  twin..  Med.  Comment . 
Vol.  IX.  p.  380. 


cum  sensuum  obscuratione."  This  differs  from  his  definition  of 
epilepsy,  by  the  absence  of  the  character  "  periodicus ;"  and  on 
the  same  principle  Vogel  simply  defines  it  "  epilepsia  acuta."  The 
principal  difference,  and  one  of  a  highly  important  nature  in  prac- 
tice, is,  that  whilst  the  symptoms  are  the  same  in  both  diseases, 
they  arise,  in  epilepsy,  from  some  organic  affection  of  the  brain,  or 
direct  irritation  of  that  organ  ;  whilst,  in  eclampsia,  they  rather  de- 
pend on  some  sympathetic  and  temporary  cause.  Hence,  eclamp- 
sia may  be  produced  by  worms,  by  costiveness,  indigestion,  Sic. ; 
and  occasionally,  not  only  by  the  parturient  condition  of  the  uterus, 
but  also  by  other  affections  of  the  same  organ,  in  the  virgin  state. 
I  have  seen  distinct  cases  of  eclampsia,  where  the  fits  were  very 
severe,  and  repeated,  and  accompanied,  in  the  interval,  with  coma, 
or  delirium,  caused  altogether  by  menstrual  irritation,  attended 
with  severe  pain  in  the  hypogastrum  and  bearing-down  sensation. 
In  such  cases  venesection  and  purgatives  give  relief,  and  a  blister 
on  the  head  perfects  the  cure.  Fomentations,  or  the  hot  bath,  are 
also  useful,  but  opiates  arc  not  to  be  given,  at  least  at  first.  To  re- 
turn from  this  digression,  puerperal  convulsions  often  recur  exactly 
like  labour  pains,  or  are  frequently  accompanied  or  preceded  by 
them  ;  though,  when  the  convulsion  comes  on,  the  feeling  of  pain 
is  suspended,  and  often,  but  not  always,  the  uterine  contraction  is 
stoptor  diminished. (k)  The  same  observation  applies  to  excessive 
rigours,  which  are  indeed  a  species  of  convulsions,  but  are  not  at- 
tended with  distortion  of  the  face,  nor  insensibility.  If  the  patient 
be  in  a  state  of  stupor,  she  frequently  has  the  countenance  distorted 
at  intervals,  accompanied  with  some  uterine  action.  They  are 
never  preceded  by  aura,  and  the  patient  usually  recovers  sensibility 
much  sooner,  and  more  completely  during  the  intervals,  than  in 
epilepsy;  at  the  same  time  there  have  been  instances  of  the  patient 

fhj  Dr.  Clarke  of  London,  thinking  it  necessary,  in  a  case  of  convulsions,  to 
turn  the  child  and  deliver  jt,  a  convulsion  occurred  whilst  his  hand  was  in  the 
uterus,  when,  of  course,  he  had  an  opportunity  of  observing  how  it  was  affected. 
— He  remarked,  that  instead  of  a  regular  contraction  taking  place,  the  uterus 
seemed  to  ilutter,  or  be  irregularly  and  tremulously  contracted  and  relaxed  again 
quickly,  and  he  was  disposed  to  believe,  that  it  was  in  that  state  during  every 
case  of  puerperal  convulsions. 

62 


482 

remaining  in  a  stale  of  stupor  for  two  days.     The  organs  of  sense, 
particularly  the  ear,  are  often  preternatu  rally  sensible.    Sometimes 

the  child  is  unexpectedly  born  during  a  fit. 

Convulsions,  of  the  kind  I  am  considering,  evidently  are  con- 
nected with  gestation  or  parturition  ;  they  occur  at  no  other  time, 
and  are  more  frequent  in  a  first  labour.  They  arise  particularly 
from  uterine  irritation,  but  also  seem  frequently  to  be  connected 
with  a  neglected  state  of  the  bowels,  a  fact  to  which  I  wish  to  call 
the  attention  of  practitioners.  It  is  a  general  opinion,  that  preg- 
nancy produces  plethora,  and  I  do  not  mean  here  to  dispute  the 
fact,  but  distinctly  to  assert  that  we  often  confound  the  effects  of 
excitement,  with  those  of  fulness  ;  for  in  many  instances,  a  pow- 
erful stimulus  will  produce  the  same  consequences,  in  a  spare  and 
bloodless,  that  a  smaller  one  would  have  done  in  a  plethoric,  habit. 
Is  apoplexy  confined  entirely  to  the  latter  t  There  are,  perhaps, 
few  subjects  more  deserving  of  inquiry,  than  the  effects  of  irrita- 
tion of  the  extremities  of  the  nerves  supplying  the  abdominal  vis- 
cera, on  the  basis  of  the  encephalon  and  the  spinal  marrow. 

There  is  nothing  either  more  difficult,  or  more  mysterious,  in 
the  etiology  of  puerperal  convulsion,  than  of  chorea,  or  stupor,  or 
apoplexy,  or  insupportable  feeling  of  fulness  in  the  head,  from  sto- 
machic or  intestinal  irritation,  connected  with  costiveness,  worms, 
bile,  or  unhealthy  action  of  the  alimentary  canal.  If  practical  ob- 
servers know  that  these  causes  do  produce  often  such  effects, 
where  is  die  ground  of  surprise,  that  uterine  irritation,  especially 
when  associated  with  irritation  of  the  bowels,  arising  from  long  ne- 
glect, should  produce  tetanic,  spasmodic,  or  even  apoplectic  affec- 
tions, during  labour  ?  This  sympathetic  irritation  is  almost  inva- 
riably accompanied  by  an  affection  of  the  vascular  system,  pro- 
ductive of  great  determination  to  the  head,  which  aggravates  the 
evil,  and  becomes,  indeed,  the  chief  source  of  danger.*  I  shall  not, 
however,  enter  farther  into  the  theory,  but  state  the  practice,  which 
is  of  more  consequence.  The  first  object  is,  to  prevent  the  patient 

•  II  has  been  supposed  by  Sir.  Power,  that  convulsions  depend  on  a  transla- 
tion of,  what  he  calls  the  parturient  energy,  from  the  uterus  to  the  brain,  or  that 
there  is  a  metastasis  of  action. 


483 

from  injuring  the  tongue,  by  inserting  apiece  of  cork  or  wood  into 
the  mouth  ;  this  occupies  no  time.  Next,  we  bleed  the  patient, 
and  must  not  spare  the  lancet.  All  our  best  practitioners  are  agreed 
in  this,  whatever  their  sentiments  may  be  with  regard  to  the  na- 
ture of  the  disease,  or  to  other  circumstances.  We  must  bleed 
once  and  again,  whether  the  convulsions  occur  during  gestation  or 
pregnancy.*  There  is  more  danger  from  taking  too  little  blood, 
than  from  copious  evacuation.  Often,  in  a  short  time,  several 
pounds  of  blood  have  been  taken  away  with  ultimate  advantage. 
Blood-letting  also  tends  to  relax  the  os  uteri.  The  quantity  to  be- 
taken away  must  depend  on  the  severity  and  obstinacy  of  the 
symptoms.  We  never  ought  to  take  away  more  than  is  required 
for  relief;  nor  on  the  other  hand,  are  we  to  stop  prematurely.  It 
is  desirable  to  procure  the  discharge  as  speedily,  and  in  as  full 
stream,  as  possible  ;  but  it  is  not  essential,  that  it  be  taken  from  the 
jugular  vein,  nor  is  that  often  safe  or  practicable. (7)  I  have,  when 
treating  of  the  diseases  of  pregnancy,  observed,  that  in  many  ca- 
ses, affections,  arising  evidently  by  sympathy  from  a  state  of  irri- 
tation of  some  of  the  abdominal  viscera,  might  require  venesection 
for  their  removal ;  or,  if  this  were  neglected,  and  the  disease  treat- 
ed merely  by  purgatives,  protracted  illness,  or  immediate  danger, 
might  result.  Nothing  can  illustrate  this  principle  better  than  the 
present  disease,  which  requires  instant,  and  generally  a  copious 
loss  of  blood,  the  mere  removal  of  the  irritation,  which  excited  the- 
inordinate  action  of  the  nervous  and  sanguiniferous  system,  not  be- 
ing sufficient  for  the  cure.     Next,  we  administer  a  smart  clyster, 


*  La  Mottc  mentions  a  case,  222,  where  a  woman,  in  the  last  five  months  of 
pregnancy,  was  bled  eighty-six  times.  Sometimes  2  oz.  would  relieve  her. — By 
modern  practitioners,  from  40  to  80  oz.  have  been  taken  with  advantage,  in  a  case 
of  puerperal  convulsions.  Puzos  insists  on  the  necessity  of  copious  blood-letting 
and  speedy  delivery.  This  practice  is  adopted  by  the  most  judicious  of  the  pre- 
sent day. 

(/)  Where  this  cannot  be  conveniently  accomplished,  we  should  detract  blood 
very  freely  by  cupping  from  the  temples  and  back  part  of  the  neck.  I  have 
more  than  once  been  witness  to  the  best  effects  resulting  from  this  practice,  arfd 
therefore  must  here  strongly  recommend  it. 


484 

which,  if  given  early  in  the  precursory  stage,  is  of  itself  sometimes 
sufficient  to  arrest  the  progress  of  the  disease.  A  smart  dose  of 
calomel,  or  solution  of  salts,  may  also  be  given  with  advantage, 
when  the  person  can  swallow,  especially  if  the  convulsions  have  oc- 
curred during  pregnancy,  with  little  tendency  to  labour.  We  must 
also  attend  to  the  bladder,  that  it  be  emptied,  for  its  distension 
alone  has  sometimes  brought  on  convulsions.* 

One  part  of  practice,  then,  and  a  most  important  and  essential 
one,  too,  consists  in  depletion,  by  which  the  risk  of  fatal  oppression 
of  the  brain,  or  extravasation  of  blood  within  the  skull,  is  diminish- 
ed, and  the  convulsions  mitigated.  But  this  is  not  all ;  for  the  pa- 
tient is  sufferiug  from  a  disease  connected  with  the  state  of  the 
uterus,  and  the  state  is  got  rid  of  by  terminating  the  labour.  Even 
when  convulsions  take  place  very  early  in  labour,  the  os  uteri  is 
generally  opened  to  a  certain  degree,  and  the  detraction  of  blood, 
which  has  been  resorted  to  on  the  first  attack  of  the  disease,  renders 
the  os  uteri  usually  lax  and  dilatable.  In  this  case,  although  we 
have  no  distinct  labour  pains,  we  must  introduce  the  hand,  and 
slowly  dilate  it,  and  deliver  the  child.  I  entirely  agree  with  those 
who  are  against  forcibly  opening  the  os  uteri  ;f  but  I  also  agree 
with  those  who  advise  the  woman  to  be  delivered  as  soon  as  we 
possibly  can  do  it  without  violence.f  There  is,  I  am  convinced,  ho 

*  LaMotte,  223,  224. — Leake  relates  a  case  where  it  produced  subsultus  tendi- 
itum,  and  excessive  pain  at  the  pubis.    Vol.  II.  p.  344. 

f  Dr..  Bland  is  rather  against  delivery,  and  for  trusting  to  nature.  Dr.  Garth- 
shore,  Jour.  VIII.  359,  says,  more  women  have  recovered  of  this,  who  were  not 
delivered,  than  of  those  who  were  violently  delivered. — Dr.  Denman  concludes, 
that  women,  in  the  beginning  of  labour,  ought  not  to  be  delivered,  II.  381,  and 
admits  of  it  only  when  it  can  be  done  easily. — Baudelocque  says,  that  we  ought 
not  to  be  in  haste  to  deliver,  and  never  to  do  it  when  nature  seems  to  be  dis- 
posed to  do  it  herself.  Dr.  Hull,  Obs.  &c.  p.  245,  says,  that  we  should  trust  to 
the  usual  remedies,  till  the  os  uteri  be  easily  dilatable,  or  be  dilated,  and  then  de- 
liver. He  informs  me,  that  in  every  case  which  proved  fatal,  there  was  no  dila- 
tation of  the  os  uteri.  Gardien  is  disposed  to  limit  the  propriety  of  delivery  to 
those  casas,  where  there  is  great  sensibility  of  the  os  uteri,  with  pain  at  the  ex- 
ternal parts.    Traite,  Tome  II.  p.  424. 

*  Dr.  Osborn,  p.  50,  says,  that  no  remedy  can  be  used  with  any  reasonable  ex- 
pectation of  benefit,  till  delivery  is  completed  ;  and  that  therefore  it  is  our  in- 
dispensable duty  to  effect  it  in  the  quickest  possible  manner. — Dr.  J.  Hamilton- 


485 

rule  of  practice  more  plain  or  beneficial,*  when  evacuations  fail  ta 
check  the  convulsions.  It  not  only  removes  an  original  cause,  but 
also  puts  a  stop  to  that  renewed  aggravation  of  symptoms,  which 
attends  on  every  pain  or  effort,  whether  it  be  called  parturient  or 
convulsive.  Delivery  does  not,  indeed,  always  save  the  patient, 
or  even  prevent  the  occurrence  of  the  fits,  but  it  does  not  thence 
follow  that  it  ought  not  to  be  adopted.  I  look  upon  it  as  indis- 
pensable, if  the  convulsions  are  not  checked  by  venesection.  When 
the  os  uteri  is  rigid,  the  hip-bath  and  emollient  vaginal  injections 
have  been  recommended,  but  they  are  useless  as  well  as  trouble- 
some. The  application  of  extract  of  belladona  has  been  proposed 
for  removing  rigidity,  but  of  this  I  have  no  experience,  and  believe 
that  if  venesection  do  not  produce  relaxation,  nothing  else  can.  In 
obstinate  rigidity  the  os  uteri  has  been  cut  with  advantage.  In  al- 
most every  instance  the  forceps  arc  applicable,  and  turning  is 
rarely  required.  Indeed,  if  the  water  has  been  evacuated,  it  is  very 
questionable  how  far  the  irritation  attending  it  would  be  safe. 

Internal  remedies  have  been  advised,  such  as  opium,  and  musk, 
and  camphor  j  but  experience  does  not  establish  the  utility  of  the 
two  last,  and  the  first  is  highly  dangerous,  tending  to  convert  the 
disease  into  fatal  apoplexy.  If  in  any  case  it  be  admissible,  copious 
venesection  must  precede  it,  and  the  bowels  must  have  been  open- 
ed. In  general  it  is  to  be  strictly  avoided,  as  the  most  fatal  agent 
which  can  be  employed,  and  is  only  admissible  when  there  is  acute 
•and  obstinate  pain  in  the  head  or  stomach,  which  has  resisted  the 
lancet,  and  the  application  of  a  sinapism  to  the  part. 

The  practice,  then,  which  may  be  deduced  from  the  view  I  en- 
tertain of  the  nature  and  causes  of  puerperal  convulsions,  and  which 
independently  of  all  theory,  comes  recommended  by  experience, 
is,  first,  to  detract  blood  j  second,  to  remove  intestinal  irritation  by 

Annals,  V.  318.  et  seq.  says,  that  when  convulsions  occur  during  labour,  delivery 
is  to  be  accomplished  as  soon  as  possible. — Dr.  Leake,  that  when  they  seem  to 
proceed  from  the  uterus,  speedy  delivery  is  useful ;  but  when  from  "  any  cause 
independent  of  the  state  of  pregnancy,"  delivery  would  be  hurtful,  11.  348. 

*  Even  evacuating  the  liquor  amnii  has,  M.  Baudelocque  admits,  been  of  ser- 
vice, §  1118.  In  one  case  the  os  uteri  was  hard  and  callous,  it  was  divided,  the 
child  speedily  born,  and  the  woman  immediately  became  calm,  1120. 


486 

clysters,  and  afterwards  by  purgatives,  which,  although  they  may 
not  immediately,  yet  will  ultimately  produce  beneficial  effects; 
third,  to  get  rid  of  the  uterine  action,  by  accomplishing  delivery, 
when  that  can  be  done,  without  much  irritation  ;  fourth,  to  avoid 
every  thing  which  can  excite  the  nervous  and  vascular  system, 
such  as  cordials  and  opium. 

If  the  fits  have  been  only  apprehended,  but  have  not  taken 
place,  then  we  may  use  remedies  as  preventives.  The  most  bene- 
ficial treatment  is,  to  empty  the  vessels  and  the  bowels.  When  | 
there  are  evident  symptoms  of  disordered  stomach,  a  gentle  emetic 
has  been  advised  ;  but  I  have  never  seen  it  administered  myself, 
and  am,  from  its  effects  on  the  head,  not  partial  to  its  exhibition. 
When  a  violent  pain  in  the  stomach  takes  place,  we  should  bleed, 
and  if  it  shall  continue  after  that,  give  an  opiate.  I  wish  it  to  be 
carefully  remembered,  that  when  we  have  headach,  or  any  other 
symptoms  indicating  a  tendency  to  convulsions,  the  lancet  is  ne- 
cessary. Blood-letting  can  seldom  do  harm,  it  may  do  much  good ; 
and  if  this  book  serve  only  to  impress  that  fact  on  the  mind  of  one 
reader,  I  will  not  regret  having  written  it. 

When  symptoms  of  nervous  irritation  exist,  without  any  deter- 
mination to  the  head  or  fulness  of  vessels,  then,  after  bleeding, 
opiates  may  be  of  advantage.*  Camphor  has  been  strongly  re- 
commended by  Dr.  Hamilton,(/?iJ  as  the  most  powerful  internal  re- 

*  Opiates  have  been  strongly  recommended  by  some  practitioners,  particularly 
Dr.  Bland.  Journ.  Vol.  II.  p.  328,  &c. — Dr.  Hamilton  as  strongly  prohibits  them. 
Annals  of  Med.  Vol.  V. — Petit  says,  they  kill  both  the  mother  and  the  child. 

(~mJ~Dv.  Hamilton  in  an  interesting- paper  on  puerperal  convulsions,  which  he 
terms  Eclampsia,  [in  Annals  of  Medicine  for  1800,]  says,  that  no  patient  to  whose 
assistance  he  had  been  called,  who  had  taken  a  dose  of  opium  previously  to  his 
arrival,  had  ever  recovered.  Camphor  he  strongly  recommends,  and  gives  it  in 
doses  of  from  5  to  10  grains,  frequently  repeated  ;  lie  says  that  every  patient  to 
whom  it  was  possible  to  give  it,  recovered. — 'the  Digitalis  he  also  used  with  ad- 
vantage in  those  cases  where  oedema  existed. 

This  mode  of  treating  the  disease  has  proved  so  successful  in  his  hands,  that, 
in  the  paper  above  referred  to,  which  is  well  worthy  of  perusal,  he  states,  that 
in  15  months  immediately  preceding  its  publication,  he  had  attended  twelve 
cases  of  the  disease,  where  the  fits  had  occured  previously  to  his  being  sent  for  ,- 
and  although  in  more  than  a  majority  of  them,  ever}'  symptom  deemed  unfv 


467 

Biedy  which  can  be  prescribed ;  but  I  cannot,  from  my  own  ob- 
servation, say  much  respecting  its  virtues  as  a  preventive.  But 
when  convulsions  have  continued  after  delivery,  or  when  the  re- 
covery was  not  complete,  I  have  found  it  of  service,  and  recom- 
mend it  to  be  always  tried.  In  these  circumstances,  it  is  always 
proper  to  blister  and  shave  the  head. 

If  convulsions  take  place  after  the  delivery  of  the  child,  for  the 
first  time,  then  the  placenta,  if  it  have  not  come  away,  is  immedi- 
ately to  be  extracted  ;  and  if  the  pulse  do  not  expressly  forbid  it,  a 
vein  is  to  be  opened,  and  afterwards,  the  bowels  purged.  If  the 
practice  be  prompt  and  vigorous,  the  generality  of  patients  recover 
from  puerperal  convulsions. 

Those  who  have  had  convulsions  during  labour,  ought  in  a  suc- 
ceeding pregnancy  to  pay  the  utmost  attention  to  the  bowels,  avoid 
a  regimen  which  induces  plethora,  and  lose  blood  once  or  twice  ; 
when  labour  commences,  a  clyster  should  be  given,  and  die  patient 
bled  on  the  slightest  feeling  of  uneasiness  in  the  head. 

Apoplexy  may  take  place,  at  the  commencement  of  labour,  or 
during  gestation,  without  convulsions.  In  the  latter  term,  the  os 
uteri  is  rarely  affected;  but,  in  a  few  instances,  if  death  did  not  take 
place  immediately,  it  has  been  found  to  dilate  a  little.  The  prac- 
tice, in  either  case,  is  much  the  same,  and  differs  in  nothing  from 
that  to  be  followed  at  other  times.  The  chief  resource  is  the  lan- 
cet. The  child  claims  our  attention  in  this  disease.  If  it  occur 
during  labour,  and  death  be  evidently  approaching,  the  delivery 
ought  to  be  promoted  as  soon  as  possible,  by  turning  or  the  for- 
ceps, in  order  to  preserve  the  child.  If  it  occur  in  the  end  of  preg- 
nancy, the  cesarean  operation  should  be  performed  immediately 
after  death,  or  with  a  better  chance,  before  it,  for  the  mother  can^ 
not  suffer  in  such  circumstances,  being  moribund. 

ORDER  5.  WITH  RUPTURE  OF  THE  UTERUS. 
The  uterus  may  be  lacerated  during  labour,  under  different  cir- 

Vourable  concurred,  yet  every  patient  recovered. — This  is  certainly  a  favourable 
result,  for  Mauriceau  relates  21  cases  of  the  disease,  13  of  which  died.  Giftard 
mentions  4  cases,  2  of  which  perished. 


488 

cumstances,  and  from  various  causes.  Any  part  of  it  may  be  torn, 
but  generally  the  rupture  takes  place  in  the  cervix,  and  the  wound 
is  transverse.  Sometimes  the  uterus  is  entire,  and  the  vagina  alone 
is  lorn.  It  may  happen  during  any  stage  of  labour,  and  even  be- 
fore the  membranes  burst,*  but  this  is  uncommon.  It  may  take 
place  when  the  head  has  fully  entered  the  pelvis,  or  in  the  moment 
when  the  child  is  delivered.! 

The  uterus  may  be  ruptured,  by  attempts  rashly  made  to  turn 
the  child  ;J  or,  after  the  water  has  been  long  evacuated,  some  pro- 
jecting part  of  the  child  may  so  affect  a  portion  of  the  uterus,  as  to 
make  it  tear.  A  certain  set  of  fibres  may  also  be  suddenly  and 
spasmodically  contracted,  and  laceration  may  thus  take  place.  In 
these  cases,  there  is  often  very  little  warning,  and  the  accident  may 
happen  when  we  are  just  in  expectation  of  a  happy  termination  of 
the  fahour.(n)  In  a  case  detailed  by  Dr.  Douglas,  (p.  50.)  the 
liead  of  the  child  was  resting  on  the  perineum,  when  the  lady,  who 
had  been  subject  to  cramp,  uttered  a  violent  cry,  and  the  head  re- 
ceded. The  child  was  delivered,  but  the  patient  died.  Mr.  Gold- 
son's  patient  complained  of  cramp  in  the  leg,  in  the  intervals  of  the 
labour  pains ;  and  in  the  instant  when  the  rupture  happened,  she 
exclaimed  "  the  cramp !"  Dr.  Monro's  patient  (Works,  p.  677.) 
was  sitting  in  a  chair,  when  she  suddenly  screamed,  and  the  ute*- 
rus  was  lacerated ;  she  was  not  delivered,  but  lived  from  Tuesday 
till  Friday.  Rigidity  of  the  os  uteri  may  also  be  a  cause  of  lace- 
ration.^ It  dilates  very  slowly,  requires  great  exertion  of  the  ute- 
rine fibres,  and  the  patient  suffers  much  pain.     The  uterus  may  at 

*  Vide  Mem.  of  Med.  Soc.  Vol.  II.  p.  US. 

|  In  a  case  which  I  saw,  the  placenta  was  retained  by  a  spasmodic  stricture, 
though  the  child  was  expelled  ;  every  allowable  attempt  was  made  to  extract  it, 
but  in  vain.  The  uterus  acted  from  the  os  uteri  towards  the  rent,  which  was  at 
the  fundus.  The  woman  died.  The  placenta  was  found  still  in  utero.  The  in- 
testines were  inflamed.  See  also  Crantz,  de  Utero  Rupto,  p.  22  ;  and  Dr.  Cath- 
ral'scase  in  Med.  Facts,  Vol.  VIII.  p.  146. 

i  A  fatal  case  of  this  kind  is  related  to  Mr.  Dease. — One  more  fortunate  in  tiie 
issue,  is  inserted  in  Mem.  of  Med.  Soc.  Vol.  IV.  p.  253. 

(~rij  Vide  a  case  by  the  Editor,  inserted  in  the  New  York  Medical  Reposito- 
ry tor  1804.  Hexadc  2,  Vol.  I. 

?:  Perfect's  Cases,  Vol.  II.  p.  439.— -Hamilton's  Cases,  p.  138. 


489 

last  be  torn,  even  although  the  head  has  partly  descended  into  the. 
pelvis,  and  the  pelvis  be  large.  In  this  case  the  liquor  amnii  has 
been  discharged  before  the  rupture  takes  place.  The  most  fre- 
quent cause,  however,  of  this  accident,  is  a  disproportion  between 
the  size  of  the  head  and  the  capacity  of  the  pelvis,  by  which  a  por- 
tion of  the  cervix  uteri  is  pinched  between  the  head  and  the  pelvis, 
and  fixed  so,  that  the  action  of  the  uterus  is  directed  against  this 
spot,  rather  than  the  os  uteri.  The  woman  feels  very  severe  pain, 
either  in  the  back  or  at  the  pubis,  which,  during  the  action  of  the 
uterus,  augments  to  an  extraordinary  degree,  and  then  the  part 
gives  way.  Another  way  in  which  the  cervix  may  be  lacerated, 
is  by  the  linea  iliopectinea  being  so  sharp,*  that  when  the  uterus  is, 
pressed  against  it,  the  parts  are  either  cut  through,  or  so  much  act- 
ed on,  that  they  are  in  a  manner  killed,  and  give  way,  having  a 
sphacelated  appearance.  In  some  cases  the  rectum,  but  much 
more  frequently  the  bladder,  is  opened.  Preternatural  presenta- 
tions, from  the  obstacle  afforded  to  delivery,  becomes  also  a  cause 
.of  rupture. 

Now,  from  this  view  we  learn,  that  those  women  are  most  liable 
to  rupture  of  the  uterus,  who  are  very  irritable,  and  subject  to 
cramp ;  or  who  have  the  pelvis  contracted,  or  its  brim  very  sharp; 
or  who  have  the  os  uteri  very  rigid,  or  any  part  of  the  womb  in- 
durated. Scholzius  relates  a  case,  where  it  was  produced  by 
.scirrhus  of  the  fundus;  and  Friedus  one,  where  it  was  owing  to  A 
cameo-cartilaginous  state  of  the  os  uteri. (o)  Sometimes  the  ute- 
rus seems  to  be  predisposed  to  this  accident,  by  a  fall  or  bruise. 
Reidlinus  relates  one  instance  of  this.  Behling,  Steidle,  and  Per- 
fect, furnish  us  each  with  another.  Salmuthus  considers  a  thin- 
ness of  the  uterus  as  a  predisposing  cause  of  rupture;  and  Dr. 
Rossf  relates  a  case  where  it  seemed  to  have  this  effect,  the 


*  In  a  case  of  this  kind,  the  line  was  on  one  side,  as  sharp  as  a  fruit  knife,  and 
a  cartilaginous  knob  projected  from  the  symphysis.     The  bladder  was  torn. 

(~oJ  See  also  a  case  of  similar  nature  by  Dr.  M.  Anthony.   Eclectic  Repertory, 
Vol.  IV.  p.  496. 

f  Annals  of  Med.  Vol.  III.  p.  277. 

()3 


490 

womb  not  being  above  the  eighth  part  of  an  inch  thick,  and  tear- 
ing like  paper. 

We  are  led  to  anticipate  laceration,  when  the  patient  is  restless, 
and  complains  of  very  severe  local  pain,  subject  to  great  exacer- 
bation, and  attended  with  a  very  acute  or  tearing  sensation.  The 
pains  are  violent  and  frequent,  and  usually  do  not  produce  a  great 
effect  on  the  os  uteri,  which  is  often  very  rigid.  These  symptoms 
are  still  more  alarming,  if  the  liquor  amnii  have  been  fully  evacu- 
ated. The  treatment  to  be  followed,  must  depend  on  the  appa- 
rent cause  ;  rigidity,  is  to  be  overcome  by  venesection  ;  spasmodic 
action,  by  an  opiate  clyster;  change  of  structure  of  the  os  uteri, 
may  demand  consideration,  how  far  incision  may  be  proper;  mal- 
position of  the  child  must  be  rectified;  and,  finally,  when  the 
pelvis  is  contracted,  and  there  is  any  symptom,  indicating  the  risk 
of  laceration  taking  place,  the  forceps  are  instantly  to  be  employ- 
ed j  or,  when  such  symptoms  exist,  in  any  case  where  the  forceps 
are  applicable,  it  would  be  criminal  to  delay. 

When  this  accident  does  happen,  the  woman  feels  something 
give  way  within  her,  and  usually  suffers,  at  that  time,  an  increase 
of  the  pain.  The  presentation  disappears  more  or  less  speedily, 
unless  the  head  have  fully  entered  the  pelvis,  or  the  uterus  con- 
tract spasmodically  on  part  of  the  child,  as  happened  in  Behling's 
patient.*  The  pains  go  off  as  soon  as  the  child  passes  through 
the  rent  into  the  abdomen  ;  or,  if  the  presentation  be  fixed  in  the 
pelvis,  they  become  irregular,  and  gradually  decline.  The  pas- 
sage of  the  child  into  the  abdominal  cavity  is  attended  with  a  sen- 
sation of  strong  motion  of  the  belly,  and  is  sometimes  productive 
of  convulsions.  The  shape  of  the  child  can  be  felt  pretty  dis- 
tinctly through  the  abdominal  coverings. 

The  patient,  after  this  accident,  soon  begins  to  vomit  a  dark  co- 
loured fluid,  the  countenance  becomes  ghastly,  the  pulse  small  and 
feeble,  the  breathing  is  oppressed,  and  frequently  the  patient  can- 
not lie  down.  Sometimes  the  intestine  protrudes  through  the 
wound  in  the  uterus,  and  has  even  been  strangulated  in  it.  These 
symptoms  do  not  all  appear  in  every  case,  nor  come  on  alwa\  p 

*  Halter's  Disput.  Tom.  III.  p.  477. 


491 

with  the  same  rapidity.  Id  Dr.  Ross's  patient,  although  the  child 
escaped  through  a  rent  in  the  vagina  into  the  cavity  of  the  abdo- 
men, and  though  the  nature  of  the  case  was  ascertained,  yet  no 
hemorrhage,  fainting,  nor  bad  symptoms  took  place  ;  and  the  child 
being  delivered,  the  woman  recovered.fy>J 

If  the  patient  be  not  speedily  relieved,  she  becomes  very  rest- 
less, tosses  in  the  bed,  and  vomits  frequently  ;  complains  of  a  pain 
in  the  belly,  which  becomes  swelled,  the  pulse  is  rapid,  the  ex- 
tremities become  cold,  and  the  strength  sinks.  In  every  case  that 
I  have  seen,  the  intestines  were  chiefly  affected,  being  much  in- 
flamed. The  interval  which  elapses  between  the  accident  and 
death,  is  various  ;  but  generally,  whether  the  patient  be  delivered 
or  not,  she  dies  within  twenty-four  hours,  often  in  a  much  shorter 
lime.  Steidele,  however,  relates  a  case,  where  the  patient  lived 
till  the  twelfth  day  ;  Dr.  Garthshore's  patient  lived  till  the  twenty- 
sixth  day;  and  in  the  Coll.  Soc.  Havn.  Vol.  II.  p.  326.  there  is 
the  case  of  a  woman,  who  after  being  delivered,  lingered  for  three 
months. 

Different  opinions  have  been  held  respecting  the  best  mode  of 
treatment.  Some  have  advised  the  performance  of  the  caesarean 
operation,  some  delivering  per  vias  naturales,  and  others  leaving 
the  case  to  nature.  We  have  instances  of  all  these  methods  being 
successful ;  but  the  delivery,  by  turning  the  child,  has  advanta- 
ges over  the  other  modes,  and  certainly  ought,  with  scarcely  any 
exception,  to  be  resorted  to.  When  the  os  uteri  is  dilated  before 
the  accident  takes  place,  as  is  usually  the  case,  and  the  hand  can, 
without  much  difficulty,  be  introduced,  it  is  to  be  passed  through 
the  os  uteri,  and  the  rent  in  the  uterus,  into  the  abdominal  cavity, 
in  search  of  the  child's  feet,  which  are  to  be  brought  down,  and 
the  case  managed  in  the  same  way  as  in  presentation  of  the  feet. 
When  the  placenta  is  extracted,  we  are  to  introduce  the  hand  again, 
to  ascertain  that  no  part  of  the  intestines  have  protruded  through 

(p)  Dr.  Douglass'  patient  recovered  after  the  delivery  of  the  child.  Mr.  Ha- 
den's  patient  also  recovered,  after  rupture  of  the  uterus.  Vide  Med.  and  Chi- 
rargical  Transactions,  Vol.  p.  184,  seq.  In  a  case  that  occurred  to  the  editor, 
the  woman  lived  near  four  days  after  delivery,  and  gave  flattering  hopes  of  re- 
covery, but  unhappily  not  realized. 


492 

the  wound.  This  process  is  usually  easy,  when  the  rent  is  in  the 
cervix  uteri  or  the  vagina.  When  it  is  higher,  there  is  often  great 
difficulty,  owing  to  the  contraction  of  the  uterus  ;  which  may  be 
affected  spasmodically,  or  may  have  universally  contracted,  and 
the  rent  become  very  small.  It  sometimes  happens,  that  when  at- 
tempts are  made  to  carry  the  hand  through  the  cavity  of  the  uterus 
to  the  rent,  the  fibres  contract  over  the  hand,  and  the  contraction 
may  be  felt  sweeping  toward  the  rent,  so  as  to  carry,  as  it  were, 
the  uterus  off  the  hand.  It  would  be  both  cruel  and  useless  to  at- 
tempt delivery  in  such  a  case. 

When  the  os  uteri  is  rigid  and  very  little  dilated  before  the  ac- 
cident happens,  and  cannot  be  opened  without  extreme  irritation, 
which  is,  indeed,  rather  a  state  which  may  be  supposed,  than  ac- 
tually met  with  ;  or  when  the  uterus  is  spasmodically  and  violent- 
ly contracted  between  the  rent  and  the  os  uteri,  which  I  know  is 
apt  to  happen,  if  the  fundus  be  lacerated,  I  consider  attempts  to 
deliver  as  adding  to  the  danger.  These  cases  are  only  rare,  be* 
cause  the  rupture  is  generally  in  the  cervix  ;  for  when  the  body, 
or  fundus,  is  torn,  the  contraction  is  often  strong ;  and,  although 
there  be  doubtless  instances  of  delivery  being  accomplished  with 
facility  some  hours  after  the  rupture,  yet,  in  most  cases,  such  con- 
traction soon  takes  place,  as  must  altogether  prevent  it,  or  render 
it  highly  dangerous.  It  may  also  happen,  that  deformity  of  the 
pelvis  prevents  delivery.  In  such  circumstances,  we  must  either 
perform  the  caesarean  operation,  or  leave  the  case  to  nature.  If 
we  have  been  called  early,  when  the  child  is  yet  alive,  and  before 
the  abdominal  viscera  have  been  much  irritated  by  the  presence 
of  the  foetus,  we  are  warranted  to  extract  the  child  by  a  small  in- 
cision.* If  many  hours,  however,  have  elapsed,  then  such  irrita- 
tion is  often  produced,  as  renders  it  doubtful  if  the  additional  in* 

*  Vide  successful  case  by  Thibault,  in  Jour,  de  Med.  for  May  1768. — M.  Bau- 
delocque  relates  a  case  where  the  operation  was  twice  performed  on  the  same 
patient,  for  the  same  cause.  In  Essays  Phys.  and  Lit.  Vol.  II.  p.  370,  is  a  case 
•most  incredible,  where  both  the  uterus  and  abdominal  integuments  were  torn 
during  labour.  The  child  escaped,  and  the  woman  recovered.  A  case  is  relat- 
ed lately  in  one  of  the  French  Journals,  where  the  cesarean  operation  was  per- 
formed twelve  hours  after  the  rupture,  with  success. 


493 

jury  of  the  operation  could  be  sustained.  On  the  other  hand,  if 
little  irritation  be  yet  excited,  and  the  woman  is  tolerably  well, 
there  is  room,  it  may  be  said,  to  hope,  that  a  natural  cure  may  be 
accomplished,  as  in  extra-uterine  pregnancy  ;  and  therefore,  as 
the  child  cannot  be  saved  now,  it  may  be  argued  that  it  is  more- 
prudent  to  trust  to  nature.*  Even  in  this  case,  I  am  inclined  to 
extract  by  a  small  incision,  which  I  conceive  to  be  less  dangerous 
than  by  the  rent,  when  such  a  time  has  elapsed,  as  must  have  ren- 
dered the  uterus  very  tender  and  easily  irritated.  Another  risk 
arises  from  the  extravasation  of  blood  into  the  abdomen,  early  ex- 
citing inflammation  ;  and  it  has  been  proposed  by  M.  Deneux  and 
others  to  evacuate  the  blood  by  an  aperture. 

The  cases  which  admit  most  easily  of  delivery,  are  those  where 
the  rent  is  situated  in  the  cervix  uteri  or  vagina  ;  and  laceration  of 
the  vagina  is  less  dangerous  than  rupture  of  the  uterus,f  provided 

*  Astruc.  liv.  v.  chap.  iv.  quotes  a  case  where  the  child  remained  in  the  abdo- 
men for  25  years.  In  another  case,  the  midwife  felt  the  child's  head,  but  after  a 
severe  pain  it  disappeared,  and  the  woman  complained  only  of  a  weight  in  the 
belly.  It  was  expelled  by  abscess.  Ilis.  de  la  Societe  de  Med.  Tom.  I.  p.  388, 
In  Dr.  Bayle's  case,  the  child  was  retained  20  years.  Phil.  Trans.  No.  139,  p. 
997.  In  Mr.  Birbeck's  case,  the  child  was  discharged  by  the  navel.  Phil.  Trans. 
Vol.  XXII.  p.  1000.  Bromfield's  patient  did  not  get  rid  of  the  child,  but  she 
lived  for  many  years,  and  after  her  death  the  rent  was  visible.  Phil.  Trans.  Vol. 
XL1.  p.  696.  In  Dr.  Sym's  patient,  the  process  for  expelling  the  child  by  ab- 
scess was  in  a  favourable  train,  when,  by  imprudent  exertion,  fatal  inflammation 
was  excited.  Med.  Facts,  Vol.  VIII.  p.  150.  Bartholin  also  gives  cases.  Le  Dran 
relates  an  instance  where  the  uterus  was  ruptured  on  the  23d  of  April.  On  the 
13th  of  Mny  the  placenta  was  expelled ;  on  the  16th  a  tumour  appeared  at  the 
linea  alba,  which  was  opened,  and  a  child  extracted ;  the  woman  recovered. 
Obs.  Tom.  II.  ob.  92. 

j  In  a  case  communicated  to  Dr.  Hunter,  the  forceps  were  pushed  through  the 
cervix  uteri,  and  the  intervening  portion  between  the  laceration  and  the  os  uteri 
was  afterwards  cut.  The  labour  was  finished  naturally,  and  the  woman  recovered. 
Med.  Jour.  Vol.  VIII.  p.  368.  Dr.  Douglas  relates  the  successful  case  of  Mrs. 
Manning,  in  his  Observations,  p.  6.  Dr.  A.  Hamilton  gives  a  fortunate  case, 
where  delivery  saved  the  mother.  Outlines,  p.  384;  and  Dr.  J.  Hamilton,  re- 
lates one  in  his  Cases,  p.  138,  where  the  rent  had  contracted  so  much,  as  to  give 
some  difficulty  to  the  delivery.  The  case  is  instructive.  In  the  case  of  E.  Dwy- 
er,  related  by  Dr.  Labat.  (Dub.  Trans.)  recovery  took  place,  but,  in  the  next  preg- 
nancy, the  same  accident  occurred  and  proved  fatal.  In  the  2d  vol.  of  the  Trans, 
of  the  Coll.  of  Pbys.  in  Dublin,  p.  15.  Dr.  Frizel  giyes  the  case  of  Bridget  Pagan 


494 

the  bladder  be  not  injured.  I  do  not  think  it  necessary  to  make 
any  further  remarks  on  the  laceration  of  the  vagina,  as  distinct 
from  that  of  the  womb,  except  to  say,  that  delivery  may  be  prac- 
tised after  a  greater  lapse  of  time,  than  when  the  uterus  is  torn  ; 
for  the  vagina  does  not  contract. 

When  the  head'  is  engaged  in  the  pelvis,  and  cannot  recede 
after  the  womb  is  torn,  we  have  other  symptoms,  indicating  rup- 
ture of  the  uteris,  or  at  least  the  necessity  of  using  instruments. 
The  strength  sinks,  the  pains  become  useless  or  go  off,  the  patient 
vomits,  &.c. 

When,  from  precursory  symptoms,  we  expect  that  laceration  is 
about  to  take  place,  we  must  accelerate  labour,  generally  by  the 
use  of  instruments.  This  is  more  necessary  if  the  patient  have 
formerly  had  the  uterus  torn.  Turning  must  be  dangerous,  in  such 
circumstances,  after  the  water  has  been  ev-acuated,  and  before  that, 
there  can  seldom  be  any  indication  of  danger.  It  has  been  calcu- 
lated that  rupture  takes  place,  once  in  940  cases. 

ORDER  6.  WITH  SUPPRESSION  OF  URINE. 

Suppression  of  urine  may  take  place  during  labour,  in  conse- 
quence of  the  head  of  the  child  being  locked  in  the  pelvis  ;  or 

who  had  the  uterus  raptured  in  consequence  of  the  child  presenting  the  arm. 
With  great  difficulty,  and  aided  by  the  crotchet  fixed  in  the  foot  of  the  child,  he 
succeeded  in  turning  and  delivering  it,  when  he  found  the  uterus  extensively 
ruptured  at  its  cervix,  and  the  intestines  protruding.  He  replaced  the  bowels, 
and  thinks  he  prevented  a  reprotrusion  by  making  one  edge  of  the  rent  overlap 
the  other.    She  recovered. 

M.  Coffiners  gives  a  memoir  on  this  subject,  in  the  Recueil  Period.  Tom.  VI.  in 
which  he  remarks,  that  laceration  near  the  vulva  is  easily  cured;  at  the  upper 
Fateral  part  of  the  vagina,  it  is  dangerous  ;  and  at  the  anterior  and  posterior  part, 
near  the  bladder  and  rectum,  it  is  generally  mortal ;  but  in  one  case  the  woman 
recovered,  although  the  hand  could  be  introduced  into  Uie  bladder.  The  woman 
had  incontinence  of  urine  afterwards.  In  his  eighth  case,  the  child  lay  trans- 
versely and  the  vagina  was  torn,  and  filled  with  clots;  but  the  peritoneum  was 
still  entire,  and  therefore  the  wound  did  not  enter  the  abdomen.  The  uterus  was 
supported  with  a  napkin  until  the  child  was  turned.  Dangerous  symptoms 
supervened,  but  the  woman  recovered.  He  gives  fifteen  cases,  and  of  these  six 
recovered*    Several  were  produced  by  attempts  to  reduce  the  arm  of  the  child. 


495 

from  a  kind  of  paralytic  state  of  the  bladder,  produced  by  long 
retention  of  the  urine  ;  or  by  a  small  stone,  or  quantity  of  mucus, 
obstructing  the  urethra.  It  produces  tenderness,  and  great  pain, 
in  the  hypogastric  region,  which  is  also  swelled.  The  pain  is 
constant,  but  is  increased  during  every  effort  of  the  abdominal 
muscles  to  bear  down,  because  then  the  bladder  is  pressed.  It  is 
injurious  in  so  far  as  it  tends  to  impair  the  uterine  action,  and  it  is 
dangerous  on  account  of  the  risk  of  the  distended  bladder  being 
ruptured  by  the  contraction  of  the  abdominal  muscles,  or  its  giving 
way  by  a  gangrenous  rent.  The  bad  symptoms  consequent  to 
this  event  do  not  always  come  on  instantaneously,  and  sometimes 
the  bladder  still  retains  a  little  urine.  In  a  case  related  by  Mr.. 
Hey,  in  the  fourth  volume  of  Medical  Observations  and  Inquiries, 
they  did  not  take  place  till  the  second  day.  The  patient  was 
thirsty,  vomited,  had  a  frequent  desire  to  void  the  urine,  which 
she  did  very  suddenly,  but  not  more  than  a  tea  cup  full  at  once. 
The  pulse  was  quick,  the  belly  swelled,  and  pressure  gave  her  pain. 
She  died  about  the  eighth  day,  and  the  bladder  was  found  to  be  rup- 
tured at  its  upper  part. 

When  the  urine  cannot  be  passed  by  the  voluntary  efforts  of  the 
woman,  aided  sometimes  by  pressing  up  the  head  of  the  child,  the 
catheter  must  be  introduced.  The  perforations  of  the  instrument, 
however,  ought  to  be  large,  as  a  slimy  tough  mucus  in  the  urethra 
sometimes  fills  completely  those  of  the  ordinary  size.  If  the  head 
should  be  so  jammed  in  the  pelvis,  as  to  prevent  the  introduction 
of  the  catheter,  which  is  rare,  the  woman  must  be  delivered. fo ) 

In  some  cases,  although  no  water  be  made  for  a  long  time,  yel 
no  inconvenience  is  felt;  and  when  the  catheter  is  introduced 
very  little  water  is  evacuated.  This  depends  upon  a  diminished 
secretion  ;  and  although,  of  itself,  it  cannot  determine  us  to  acce- 
lerate delivery,  yet,  should  it  be  attended  with  other  bad  symptoms 
in  tedious  labour,  it  may  form  and  additional  argument  for  inter- 


fqj  An  interesting  case  of  this  nature,  is  related  by  Dr.  Merriman,  in  Edin- 
burgh Med.  &  Phys.  Journal  fqr  1810, and  in  Eclectic  Repertory,  Vol.  J.  p.  269, 
&seq. 


496 

fering,  as  then  the  functions  are  becoming  impaired,  and  effusion 
may  take  place  into  some  of  the  cavities. 

There  are  some  other  complications,  which  might  perhaps  be 
made  the  subject  of  distinct  orders ;  such  as  the  existence  of  aneu- 
rism, hernia,  &c.  &c.  but  these  may  more  properly  be  referred  to 
the  head  of  causes  requiring  the  use  of  instrumental  aid.  It  ought 
to  be  a  general  rule,  and  it  is  a  very  clear  one,  that  whenever  a 
disease  exists,  which  may  be  much  or  dangerously  aggravated  by 
a  continuance  of  the  efforts  of  labour,  that  process  ought  to  bft 
shortened,  as  much  as  possible. 


THE 

PRINCIPLES 

OF 


BOOK  III. 

OF  THE  PUERPERAL  STATE. 

CHAP.  I. 

Of  the  Treatment  after  Delivery. 

Immediately  after  the  placenta  is  expelled,  the  finger  ought  to* 
be  introduced  into  the  vagina,  to  ascertain  that  the  perineum  or 
recto-vaginal  septum  be  not  torn,  and  that  the  uterus  be  not  in- 
verted. 

Then,  if  the  woman  be  not  much  fatigued,  she  is  to  turn  slowly 
on  her  back,  and  ^i  broad  bandage  is  to  be  slipped  under  her, 
which  is  to  be  spread  evenly,  and  pinned  so  tightly  round  the  ab- 
domen, as  to  give  a  feeling  of  agreeable  support.  This  bandage 
is  made  of  linen  or  cotton  cloth  ;  and  it  is  usual  to  place  a  com- 
press over  the  uterus,  to  assist  contraction.  In  some,  if  not  in 
many  cases,  this  might  be  dispensed  with,  as  we  see  in  a  state  ol 
nature ;  but  in  general,  in  civilized  life,  it  is  useful,  if  not  abso- 
lutely necessary.  For  the  abdominal  muscles  do  not  readily  con- 
tract, so  as  to  afford  a  support  to  the  parts  within,  and  syncope, 
breathlessness,  or  other  unpleasant  effects,  may  be  the  conse- 
quence. The  wet  sheet  is  also  to  be  pulled  from  below  her,  and 
an  open  flannel  petticoat  is  to  be  put  on  ;  it  has  a  broad  top-band, 
and  is  introduced  and  pinned  like  the  bandage.     A  warm  napkin 

64 


40B 

\s  then  to  be  applied  to  the  vulva,  and  the  woman  laid  in  an  easy 
posture,  having  just  so  many  bed-clothes  as  make  her  comfortable- 
It'  she  desire  it,  she  may  now  have  a  little  panado,  after  which  we 
leave  her  to  rest.  But  before  retiring,  it  is  proper  to  ascertain 
that  the  bandage  be  felt  agreeably  tight,  that  there  be  no  consider- 
able hemorrhage,  and  that  the  after-pains  are  not  coming  on 
severely.  It  is  also  proper  to  mark  the  state  of  the  pulse,  and  to 
leave  strict  directions  with  the  nurse,  that  every  exertion,  and  all 
stimulants  be  avoided. 

Having  thus  simply  stated  what  appears  to  be  necessary,  I  must 
next  say  what  ought  to  be  avoided.  It  is  customary  with  many 
nurses,  to  shift  the  patient  completely,  and,  for  this  purpose,  to 
raise  her  to  an  erect  posture.  Now  this  practice  may  not  always 
be  followed  by  bad  consequences,  but  it  is  very  reprehensible  ; 
for  the  patient  is  thus  much  fatigued,  and  if  she  sit  up  even  for  a 
short  time,  hemorrhage  or  syncope  may  be  produced.  The  pre- 
text for  this  is  generally  to  make  the  patient  comfortable ;  and, 
indeed,  if  the  clothes  be  wet  with  perspiration  or  discharge,  there 
may  be  some  inducement  to  shift  her.  But  this  ought  to  be  done 
slowly,  without  raising  her,  and  if  she  have  been  fatigued,  not  until 
she  have  rested  for  a  little.  Another  bad  practice  is,  the  adminis- 
tration of  stimulants,  such  as  brandy,  wine,  or  cordial  waters.  I 
do  not  deny,  that  these,  in  certain  cases  of  exhaustion,  are  salu- 
tary ;  but  I  certainly  maintain,  that  generally  they  are  both  unne- 
cessary and  hurtful,  tending  to  prevent  sleep,  to  promote  hemor- 
rhage, and  excite  fever  and  inflammation.  A  third  practice,  no 
less  injurious,  is,  keeping  the  room  warm  with  a  fire,  drawing  the 
bed-curtains  close,  increasing  the  bed-clothes,  and  giving  every 
thing  warm  to  promote  perspiration.  This  is  apt  to  produce  de- 
bility, and  many  hysterical  affections,  as  well  as  a  troublesome 
species  of  fever,  which  it  is  often  difficult  to  remove.  It  also  ren- 
ders the  patient  very  susceptible  of  cold,  and  a  shivering  fit  is  very 
readily  excited.  Lastly,  gossiping  and  noise  of  every  kind,  is 
hurtful,  by  preventing  rest,  occasioning  headach  or  palpitation,  a| 
well  as  other  bad  symptoms. 

.  At  our  next  visit,  which  ought  to  be  within  twelve  hours  after 
delivery,  we  should  inquire  whether  the  patient  have  slept,  and, 


499 

ascertain  that  the  pulse  be  not  frequent,  that  the  after-pains  have 
not  been  severe,  nor  the  discharge  copious.  We  should  also  par- 
ticularly inquire  if  she  have  made  water ;  and  if  she  have  not,  but 
have  a  desire  to  do  so  without  the  power,  a  cloth  dipped  in  warm 
water,  and  wrung  prettry  dry,  should  be  applied  to  the  pubis.  If 
this  fail,  the  urine  will  often  be  voided  if  the  uterus  be  gently  raised 
a  little  with  the  finger,  or  the  catheter  may  be  introduced.  There 
are  two  states  in  which  we  are  very  solicitous  that  the  urine  be 
voided ;  the  first  is,  when  the  patient  has  much  pain  in  the  lower 
belly,  with  a  desire  to  void  urine  ;  the  second  is,  after  severe  or 
.instrumental  labour. 

A  stool  should  be  procured  within  twenty-four  or  thirty-six 
hours  after  delivery,  either  by  means  of  a  clyster  or  a  gentle  laxa- 
tive. If  the  patient  usually  have  the  milk-fever  smartly,  or  the 
breasts  are  disposed  to  be  painful  and  tense,  a  mild  dose  of  some 
saline  laxative  is  better  than  a  clyster.  But  if  she  be  delicate,  and 
have  formerly  had  little  milk,  a  clyster  is  to  be  preferred.  If  she 
is  not  to  suckle  the  child,  then  the  laxative  should  be  rather  brisker, 
and  may  be  repeated  at  the  interval  of  two  days. 

After  delivery,  there  is  a  discharge  of  sanguineous  fluid  from  the 
uterus  for  some  days,  which  then  becomes  greenish,  and  lastly 
pale,  and  decreases  in  quantity,  disappearing  altogether  within  a 
month,  and  often  in  a  shorter  time.  This  is  called  the  lochial  dis- 
charge. During  this  time,  it  is  necessary  that  the  vaginal  and  ex- 
ternal parts  be  daily  washed  with  tepid  milk  and  water. 

During  the  latter  end  of  gestation,  milk  is  generally  secreted  in 
a  small  quantity  in  the  breasts,  and  sometimes  it  even  runs  from  the 
nipples.  After  delivery  the  secretion  increases,  and  about  the  third 
day  the  breasts  will  be  found  considerably  distended.  Many  wo- 
men, indeed,  complain  at  this  time  of  much  tension  and  uneasiness, 
and  there  is  usually  some  acceleration  of  the  pulse.  A  pretty  smart 
fever  may  even  be  induced,  which  is  called  the  milk-fever.  The 
best  way  to  prevent  these  symptoms  from  becoming  troublesome, 
is  to  keep  the  bowels  open,  and  apply  the  child  to  the  breasts  be- 
fore they  have  become  distended.  This  may  generally  be  done 
twelve  hours  after  delivery. 


500 

>The  diet  of  women  in  the  puerperal  state  ought  to  be  light;  and 
if  they  are  not  to  give  suck,  liquids  should  be  avoided,  the  food 
must  be  of  the  dry  kind,  and  thirst  should  be  quenched,  rather 
with  fruit  than  with  drink.  If  they  are  to  nurse,  the  diet  for  the 
first  two  days  should  consist  of  tea  and  cold  toasted  bread  for  break - 
fast,  beef  or  chicken  soup  for  dinner,  and  panado  for  supper ;  toast 
water,  or  barley  water,  may  be  given  for  drink,  but  malt  liquor 
should  be  avoided.  Unless  the  patient  be  feeble,  and  at  the  same 
time  have  no  fever,  wine  should  not  be  allowed  for  the  first  two 
days ;  a  little  may  then  be  added  to  the  panado  or  sago,  which  is 
taken  for  supper ;  and  a  small  glass  diluted  with  water,  maybe 
taken  after  dinner.  A  bit  of  chicken  may  be  given  for  dinner,  and 
in  proportion  as  recovery  goes  on,  the  usual  diet  is  to  be  returned 
to. 

The  time  at  which  the  patient  should  be  allowed  to  rise,  to  have 
the  bed  made,  must  be  regulated  by  her  strength  and  other  cir- 
cumstances. It  ought  never  to  be  earlier  than  the  third  day,  and, 
in  a  day  or  two  longer,  she  may  be  allowed  to  be  dressed,  and  sit  a 
little ;  but  even  in  the  best  recovery,  and  during  summer,  the  wo- 
man ought  not  to  leave  her  room  within  a  week.  She  ought  not 
to  go  out  for  an  airing,  in  general,  till  the  third  week.  In  cold 
weather,  and  when  the  patient  is  delicate,  she  must  be  longer  con- 
fined. By  rising  too  soon,  and  making  exertion,  a  prolapsus  uteri 
may  be  occasioned,  and  still  more  frequently  the  lochia  are  ren- 
dered profuse,  and  the  strength  impaired.  If  there  be,  or  have 
formerly  been,  the  smallest  tendency  to  prolapsus,  it  is  absolutely 
necessary  to  keep  the  patient,  very  much  for  some  time  in  a  recum- 
bent posture,  on  a  sofa,  avoiding,  however,  that  degree  of  heat 
which  relaxes  the  system.  It  is  also  necessary  in  this  case  to  sti- 
mulate the  uterine  lymphatics  to  absorption  by  a  smart  purgative 
once  in  the  three  or  four  days,  to  bathe  the  external  parts  with  rose 
water,  having  a  third  part  of  spirits  added  to  it,  and  at  the  end  of  a 
fortnight  begin  a  tonic,  mixed  with  a  mild  diuretic. 


501 

CHAP.  II. 

Of  Uterine  Hemorrhage. 

In  natural  labour,  after  the  expulsion  of  the  child,  the  uterus 
contracts  so  much  as  to  loosen  the  attachment  of  the  placenta  and 
membranes  to  its  surface,  and  afterwards  to  expel  them.  This 
process  is  always  accompanied  by  the  discharge  of  blood,  but  the 
quantity  in  general  is  small.  If,  however,  the  uterine  fibres  should 
not  duly  contract  after  the  delivery  of  the  child,  so  as  to  diminish 
the  diameter  of  the  vessels,  and  at  the  same  time  accommodate 
the  size  of  the  womb  to  the  substance  which  still  remains  within  it; 
then,  provided  the  placenta  and  membranes  be  wholly  or  in  part 
separated,  the  vessels  which  passed  from  the  uterus  to  the  ovum, 
shall  be  open  and  unsupported,  and  will  pour  out  blood  with  an 
impetuosity  proportioned  to  their  size  and  the  force  of  the  circu- 
lation. This  flow  will  continue  until  syncope  check  it,  a  state  too 
often  only  the  prelude  to  death. 

It  is  evident  that  the  cause  of  flooding  is  the  torpor  of  the  ute- 
rus.* The  fibres  may  become  inactive,  or  have  their  tonic  con- 
traction impaired  immediately  after  the  pain  which  expels  the 
child.  This  will  more  especially  happen  if  the  woman  be  weakly, 
if  the  labour  have  been  tedious,  and  the  child,  at  last  expelled  sud- 
denly by  a  strong,  but  perhaps  only  momentary  contraction. 

The  hemorrhage,  therefore,  appears  very  soon  after  delivery, 
and  before  the  placenta  has  come  away.  It  is  profuse,  and  pro- 
duces the  usual  effects  of  hemorrhage  on  the  system,  and  these  ef- 
fects are  greater  and  more  speedy  than  those  which  follow  from 
hemorrhage  before  delivery,  for  the  loss  is  instant  and  extensive. 
The  first  gush  indeed  does  not  produce  great  debility,  because  it 


*  When  the  uterus  contracts  properly  after  the  delivery  of  the  child,  it  will  be 
felt,  if  the  hand  be  applied  on  the  abdomen,  like  a  hard  and  solid  mass ;  but 
when  torpid,  it  is  not  so  distinctly  felt,  for  it  is  softer,  being  destitute  of  tonic 
contraction. 


502 

consists  chiefly  of  blood,  which  formerly  circulated  m  the  uterus, 
and  is  not  taken  directly  from  the  general  system  ;  and  the  separa- 
tion of  the  placenta  not  being  wholly  effected  at  once,  the  loss  at 
first  is  more  slow.  But  immediately  after  this,  the  effect  appears 
in  all  its  danger ;  and  it  is  not  unusual  for  the  woman,  if  not  assist- 
ed, to  die  within  ten  minutes  after  the  birth  of  the  child.* 

If  flooding  occur  after  delivery,  the  woman  says  there  is  surely 
an  unusual  discharge  ;  and,  on  examining,  it  is  found  to  be  really 
so  ;  but  at  first  the  pulse  is  pretty  good,  and  the  countenance  is  not 
much  altered.  In  a  minute,  perhaps,  the  pulse  sinks,  the  face  be- 
comes pale,  the  hands  cold,  the  respiration  is  performed  with  a 
sigh,  or  after  lying  quiet  for  a  little,  a  long  sigh  is  fetched,  and  the 
patient  seems  as  if  trying  to  awake  from  a  slumber.  She  exclaims 
--lie  is  sick,  and  immediately  vomits;  she  throws  out  her  arms,  turns 
off  the  bed-clothes,  and  seems  anxious  for  breath ;  she  complains 
of  cold,  or  perhaps  is  restless,  and  begs  not  to  be  disturbed  ;  or 
lies  in  a  state  approaching  to  syncope,  or  gazes  wildly  around  her, 
and  is  extremely  restless,  breathes  with  difficulty,  and  quickly  ex- 
pires.    The  danger  of  flooding  is  universally  known,  and  the  con- 

•  The  patient  may  die  speedily  after  the  birth  of  the  child,  in  consequence  of 
other  causes,  some  of  which  it  may  not  be  improper  to  notice.  Sudden  death 
may  proceed  from  an  organic  affection  of  the  heart,  such  as  ossification  of  the 
valves  or  arteries,  dilatation  of  the  cavities  of  the  heart,  or  aneurism  of  the  aorta. 
The  effect  of  any  sudden  change  in  the  system,  in  these  cases,  must  be  known 
to  every  practitioner.  "Whenever  we  suspect  such  disease,  the  most  perfect  rest 
must  be  observed  after  delivery.  Should  there  be  any  inequality  in  the  size  of 
the  two  ventricles,  the  right  being  larger,  for  instance,  than  the  left,  then  any 
cause  capable  of  hurrying  the  circulation,  may  make  both  sides  contract  to  their 
utmost,  the  consequence  of  which  is,  that  all  the  blood  in  the  right  side  is  thrown 
out,  but  it  cannot  be  received  into  the  left :  rupture  of  the  pulmonary  vessels 
must  take  place,  and  I  have  known  many  instances  where  the  patient  was  imme- 
diately suffocated.  Speedy  death  may  also  arise  from  the  brain  becoming  affect- 
ed in  a  way  similar  to  that  which  takes  place  in  puerperal  convulsion.  In  this 
cs9e,  the  first  symptom  is  pain  of  the  stomach,  and  the  patient  may  die  before  any 
farther  effect  is  produced.  Great  difficulty  of  breathing,  and  most  alarming,  if 
not  fatal  syncope  may  take  place,  from  the  mere  emptying  of  the  uterus,  if  an 
adequate  support  have  not  been  given,  as  we  also  sometimes  see  after  tapping 
for  dropsy.  In  this  case,  even  when  due  attention  was  paid  to  the  application  of 
a  bandage,  I  have  seen  gasping  and  alarming  weakness  produced.  The  best  re- 
meilv  i-s  an  opiate  in  such  a  case,  with  a  little  warm  wine  or  brandy. 


503 

stemation  excited  by  it,  is  in  many  cases  great.  One  exclaims 
(lie  patient  is  dead,  and  another  she  is  dying,  one  is  wringing  hex' 
hands,  another  running  for  cordials,  and  it  requires  no  small  stea- 
diness and  composure  in  the  practitioner  to  prevent  mischievous 
interference,  or  procure  necessary  aid. 

The  torpor  of  the  uterus  is  sometimes  so  universal,  that  when 
the  hand  is  introduced,  it  passes  almost  up  to  the  stomach.  But 
generally  a  circular  band  of  fibres  contracts  spasmodically  about 
the  middle  of  the  uterus,  inclosing  the  placenta  above  it,  whilst  the 
rest  of  the  fibres  become  relaxed.  This  has  not  inaptly  been  call- 
ed the  hour-glass  uterus  ;  and  if  I  did  not  know  the  hazard  of  es- 
tablishing a  general  rule,  I  would  say,  that  in  almost  every  instance, 
this  contraction  takes  place.  T  have  scarcely  ever  introduced  the 
hand  into  the  uterus  in  a  case  of  flooding,  without  meeting  with  it, 
whether  the  placenta  had  or  had  not  been  expelled.  When  it  is 
not  present  or  recognised,  I  must  suspect  that  it  is  owing  to  an  al- 
most moribund  state  of  the  womb,  and  must  be  a  very  bad  symp- 
tom. 

From  this  view  it  is  evident,  that  flooding  is  to  be  prevented  by 
preserving  the  action  of  the  uterus,  and  avoiding  whatever  can  in- 
crease the  force  of  the  circulation.  A  powerful  means  of  keeping 
up  the  action  of  the  womb,  consists  in  preventing  it  from  emptying 
itself  very  suddenly.  It  frequently  happens,  when  the  child  is  in- 
stantaneously expelled  by  a  single  contraction,  being  in  a  manner 
projected  from  the  uterus,  or  when  the  body  is  speedily  pulled 
out,  whenever  the  head  is  born,  that  hemorrhage  takes  place.  De- 
livery, therefore,  is  not  to  be  hurried,  the  steps  of  expulsion  should 
be  gradual ;  instead  of  pulling  out  the  body  of  the  child,  we  should 
rather  retard  the  expulsiou  when  it  is  likely  to  take  place  rapidly. 
Those  who  estimate  the  dexterity  and  skill  of  an  accoucheur,  by 
the  velocity  with  which  he  delivers  the  infant,  ground  their  good 
opinion  upon  a  most  dangerous  and  reprehensible  conduct ;  and 
he  who  adopts  this  practice,  must  meet  with  many  untoward  ac- 
cidents, and  produce  many  calamities.  On  the  other  hand,  severe 
and  protracted  labour,  is  no  less  apt  to  be  followed  by  irregular 
contraction  of  the  uterus,  and  hemorrhage. 

Another  mean  of  exciting  the  uterine  actioD,  is*  by  supporting 


504 

the  abdomen,  and  making  gentle  pressure  on  it  with  the  hand  im- 
mediately after  delivery.  I  do  not  say  that  this  'practice  is  in 
every  instance  necessary,  but  it  is  so  generally  useful,  that  it  never 
ought  to  be  omitted.  The  circulation  is  also  to  be  moderated  by 
the  free  admission  of  cool  air,  by  lessening  the  quantity  of  bed- 
clothes, by  a  state  of  perfect  rest,  and  by  avoiding  the  exhibition 
of  stimulants.  If  these  directions,  which  are  few  and  simple,  be 
attended  to,  we  shall  seldom  meet  with  hemorrhage  after  the  de- 
livery of  the  child.  Some  women,  no  doubt,  are  peculiarly  sub- 
ject to  this  accident.  They  are  generally  of  a  lax  fibre,  easily  fa- 
tigued and  fluttered,  and  subject  to  hysterical  affections.*  When 
a  woman  is  known  to  be  subject  to  hemorrhage,  we  should  give 
her  a  full  dose  of  laudanum  immediately  after  delivery,  excite  the 
action  of  the  uterus  by  external  pressure  or  friction  :  and,  on  the 
f}rst  appearance  of  discharge,  perhaps  in  some  instances  whenever 
the  child  is  born,  we  ought  to  introduce  the  hand  into  the  uterus. 
We  are  not  to  meddle  with  the  placenta,  or  endeavour  to  extract 
it ;  our  object  is  to  excite  the  contraction  of  the  womb,  and  make 
it  in  clue  time  expel  the  secundines.  This  gives  little  pain,  and 
may  be  attended  with  most  important  consequences  to  the  future 
health  or  comfort  of  our  patient.  1  need  scarcely,  I  think,  add, 
that  in  every  case,  more  especially  in  those  where  the  labour  has 
been  tedious,  or  the  woman  has  been  subject  to  hemorrhage,  we 
ought  not  to  leave  the  bed-side,  but  should  examine  frequently,  to 
ascertain  that  there  is  no  unusual  discharge. 

The  instant  a  woman  is  seized  with  hemorrhage  after  delivery, 
we  ought  to  take  steps  for  exciting  the  contraction  of  the  uterus, 
upon  which  alone  we  place  our  hopes  of  safety.f     Some  powerful 

*  During-  pregnancy,  there  is  sometimes  a  scorbutic  or  hemorrhagic  diathesis 
induced,  marked  by  vibices,  spongy  gums,  bleeding  from  these  or  from  the  nose, 
or  from  a  small  wound,  or  after  extraction  of  a  tooth.  If  this  be  not  corrected 
by  strengthening  diet,  the  free  use  of  fruit  and  vegetables,  and  attention  to  the 
bowels,  uterine  hemorrhage  of  an  obstinate  description  may  take  place  after  de- 
livery. Dry  diet  and  laxatives  have  been  proposed,  for  those  who  were  liable 
to  hemorrhage  ;  but  the  most  effectual  preventive,  is  due  regulation  of  the  la- 
bour and  exciting  the  uterine  action  after  delivery. 

-j-  It  is  a  fatal  error  to  wait  until  dangerous  symptoms  appear :  many  weeks  of 
suffering,  perhaps  death  itself,  may  be  the  consequence.    I  cannot  therefore 


£05 

means  are  at  all  times  within  our  reach.  Friction,  the  application 
of  cold,  and  the  introduction  of  the  hand  into  the  cavity  of  the 
uterus.  These  are  aided  by  the  instant  exhibition  of  fifty  drops 
of  laudanum. 

The  retention  of  the  placenta  is  not  in  general  the  cause  of  the 
hemorrhage,  but  a  joint  effect,  together  with  it,  of  the  torpor  of  the 
uterus.  Our  primary  object,  therefore,  is  not  to  extract  the  pla- 
centa, but  to  excite  the  uterus  to  brisker  action. (r)  How  im- 
proper and  dangerous  then  must  it  be  to  thrust  the  hand  into  the 
uterus,  grasp  the  placenta,  and  bring  it  instantly  away ;  or  to  en- 
deavour to  deliver  the  placenta  by  pulling  forcibly  at  the  umbilical 
cord.  By  the  first  practice,  we  are  apt  to  injure  the  uterus,  and 
certainly  cannot  rely  upon  it  for  checking  the  hemorrhage.  By 
the  second,  we  either  tear  the  cord  or  invert  the  uterus.  Yet,  al- 
though this  be  correct,  I  must  not  carry  the  rule  too  far.  The 
placenta  is  retained,  because  the  uterus  does  not  act  vigorously ; 
but,  in  considerable  torpor,  I  am  inclined  to  think,  that  it  may 
sometimes  act  injuriously,  by  preventing  the  uterus  from  collaps- 
ing, whilst  it  does  not,  on  the  other  hand,  make  any  stimulating 
pressure  against  its  surface,  as  can  be  done  by  the  hand.  The 
mere  removal  of  the  placenta,  after  the  womb  has  been  excited  by 
the  introduction  of  the  hand  to  lay  hold  of  it,  allows  the  sides  of 
the  now  empty  cavity  to  fall  together,  and  this  of  itself  stimulates 
to  contraction,  as  the  discharge  of  the  water  does  during  labour. 

agree  with  the  ingenious  M.  Le  Roy,  in  the  following  directions  respecting  he- 
morrhage after  the  birth  of  the  child.  Quand  la  femme  n'est  pas  delivree,  et 
qu'il  survient  une  perte,  il  faut  attendre  patiement  s'il  ne  se  manifest  aucuu 
symptome  alarmant,  parce  que  cette  perte  cesse  quelqucfois  d'elle-meme.  Mais 
quand  les  symptomes  sont  alarmans,  et  qu'on  craint  pour  la  vie  de  la  femme, 
Jorsque  !a  matrice  s'engorge  et  se  degorge  alternativement,  lorsqu'enfin  la  femme 
se  plaint  d'eblouissemens  dans  les  yeux,  deviennent  convulsifs,  que  le  pouls  de- 
vient  trop  petit,  que  les  extremites  sont  froid,  le  visage  d'une  paleur  mortelle, 
que  le  sang  traverse  le  lit,  qu'on  entend  dans  le  ventre  des  gemissemens  qui  an- 
noncent  la  resolution  des  forces  vitales,  alors  il  faut  employer  des  moyens  propre 
a  redonner  du  ressort  a.  la  matrice."     Legons.  p.  50. 

(r)  As  the  most  prominent  indication  in  these  cases  would  appear  to  be  to  ex- 
cite powerful  contraction  of  the  uterus,  the  ergot,  or  secale  cornutum,  might 
here  be  given  with  advantage,  in  the  manner  heretofore  mentioned. 

65 


506 

Hence  the  manual  abstraction  of  coagula,  if  hemorrhage  take  place 
after  the  expulsion  of  the  placenta,  is  of  signal  benefit,  often  of 
more  advantage  than  retaining  the  hand  longer  in  the  uterus. 

When  we  introduce  the  hand,  we  conduct  it  to  the  placenta, 
using  the  cord  only  as  a  director.  We  do  not  attempt  to  bring  it 
away,  but  press  upon  it  with  the  back  of  the  hand,  to  excite  the 
uterus  to  separate  it;  or,  if  it  be  already  detached,  and  lying  loose 
in  the  cavity  of  the  womb,  we  move  the  hand  gently  to  stimulate 
the  uterus,  but  do  not  withdraw  it,  nor  extract  the  placenta,  until 
we  have,  by  gentle  motion  or  pressure,  excited  the  uterus,  and 
feel  it  contracting,  or  until  we  are  satisfied  that  the  pressure  of  the 
hand  is  not  effecting  this  purpose.  In  this  case,  on  the  principle 
just  noticed,  we  ought  to  remove  both  the  hand  and  the  placenta 
at  once,  and  several  coagula  are  often  propelled  along  with  these, 
the  uterus  contracting  so  as  to  put  an  immediate  end  to  all  farthei 
anxiety. 

Friction  is  of  evident  advantage,  in  exciting  the  uterus.  It  is 
effected  by  placing  the  hand  firmly  on  the  abdominal  parietes,  and 
moving  these  briskly,  but  not  rudely  over  the  uterus,  and  occa- 
sionally grasping  that  viscus  gently.  This  remedy  has  been  often 
employed  with  success,  and  is  very  properly  recommended 
strongly  by  Gardien  and  Power. 

The  contraction  of  the  uterus  will  be  powerfully  assisted  by  the 
application  of  cold.  The  quantity  of  clothes  should  be  lessened  ; 
but  our  principal  object  is  to  apply  cold  as  a  topical  remedy  ; 
which  should  be  done  if  the  other  means  fail.  Cloths  dipped  in 
cold  water  should  be  laid  suddenly  upon  the  belly,  or  cold  water 
may  be  thrown  upon  it.  In  obstinate  cases  it  has  been  found 
useful  to  project  it  forcibly  with  a  syringe.  We  may  in  desperate- 
cases  dip  a  sponge  or  a  piece  of  cloth  in  cold  water,  and  carry  it 
in  the  hollow  of  the  hand  into  the  uterus.  Nay,  ice  itself  has, 
with  happy  effects,  been  introduced  into  the  womb.*     In  general. 

*  Saxtorph  uses  injections  of  vinegar  and  cold  water.  Pasta  has  the  hardihood 
to  use  alcohol  and  acids,  to  cauterize,  as  it  were,  the  mouths  of  the  uterine  ves- 
sels, which  cannot  fail  to  cause  inflammation.  Others  introduce  a  sponge  dipped 
in  cold  water,  or  a  sow's  bladder,  which  they  afterwards  blow  up  with  air,  to 
press  on  the  uterine  surface,  or  fill  it  with  cold  water,  at  the  same  time  that  they 


507 

However,  the  external  application  of  cold  will  be  sufficient  to  save 
the  patient.  I  feel  confident  in  advising  it,  and  can  say,  without 
reserve,  that  I  have  never  known  any  bad  consequence  result  from 
\t.(s) 

The  uterus,  in  such  cases,  generally  contracts  spasmodically,  like 
an  hour-glass,  either  before  or  after  the  expulsion  of  the  placenta.* 
This  spasm  of  the  uterus  is  an  almost  invariable  attendant  on  he- 
morrhage, and  is  accompanied  with  severe  pain  in  the  back,  great 
depression  of  strength,  and  a  very  feeble  pulse,  sickness,  and  pale- 
ness, and  last  of  all  uterine  hemorrhage,  which  occurs  early,  and  is 
often  profuse  ;  but  it  is  not  the  sole  cause  of  the  sinking  and  debi- 
lity, for  these  often  precede  even  internal  hemorrhage,  though  they 
are  speedily  increased  by  it  to  an  alarming  degree.  If  a  patient 
feel  sick  or  weak,  or  the  pulse  sink,  or  she  become  pale  soon  after 
delivery,  whether  there  be  or  be  not  hemorrhage,  we  may  be  sure 
that  this  spasm  has  taken  place,  and  that  nothing  but  prompt  mea- 

apply  external  pressure.  Others  use  the  cold  bath  itself.  Le  Roy  rubs  the  ab- 
domen with  spirits,  and  Lapira  praises  the  external  application  of  a  strong  solu- 
tion of  carbonate  of  ammonia.  Gardien  supposes  it  may  sometimes  be  so  active 
as  to  require  the  lancet.  Others  plug  the  os  uteri,  and  compress  the  abdomen. 
I  do  not  think  it  necessary  to  comment  on  these  proposals. 

(s)  It  appears  from  a  late  publication,  that  a  novel  mode  of  restraining  uterine 
hemorrhage,  (taking  place  after  parturition)  has  been  attended  with  success,  in 
Paris.  It  has  been  introduced  by  M.  Evrat,  and  is  as  follows; — A  lemon  is  de- 
prived of  its  rind  and  skin,  and  its  cells  exposed  over  its  whole  surface.  This  is 
introduced  into  the  cavity  of  the  uterus,  in  the  hand  of  the  operator;  by  this 
means  the  blood  flowing  over  the  surface  of  the  lemon  can  wash  off  only  the 
juice  that  it  meets  with,  but  the  innumerable  cells  of  which  the  fruit  is  composed, 
remain  untouched.  The  contraction  of  the  uterus  is  soon  excited  by  the  pre- 
sence of  the  hand,  and  some  drops  of  the  citric  acid.  It  is  at  this  instant,  that  by 
forcibly  squeezing  the  lemOn,  its  pure  juice  flows,  without  any  admixture  or  di- 
lution ;  and  acts  immediately  on  the  internal  surface  of  the  uterus.  M.  Evrat 
advises,  that  in  withdrawing  the  hand,  the  remainder  of  the  lemon  should  be  left 
in  the  uterus,  supposing  that  it  will  excite  the  regular  tonic  contraction  of  the 
uterine  fibres,  and  thus  prevent  any  return  of  the  hemorrhage.  The  uterus, 
when  it  contracts  completely,  will  expel  the  compressed  lemon,  as  happened  in 
a  case  related  in  the  work  alluded  to. 

*  Some  have  denied  that  the  placenta  was  retained  by  spasm,  but  imagined 
that  the  cyst,  in  which  it  lay,  was  produced  by  the  torpor  of  the  part,  whilst  all 
the  rest  contracted ;  or  from  the  uterus  contracting  round  the  placenta. 


oiues  can  preserve  life.  This  effect  of  spasm,  in  causing  debility, 
independently  of  the  actual  quantity  of  blood  lost,  or  altogether  dis- 
proportionate to  it,  is  analogous  to  the  effect  of  spasm  of  the  sto- 
mach. We  are  immediately  to  give  a  full  dose  of  laudanum.  We 
must  also,  without  loss  of  time,  introduce  the  hand  into  the  uterus, 
and  slowly  and  cautiously  dilate  the  stricture,  so  as  to  get  the  hand 
into  the  upper  cyst  of  the  uterus,  thus  stimulating  to  universal  and 
regular  contraction  ;  and  in  doing  so,  we  shall  he  greatly  assisted 
by  applying  cold  water  to  the  abdomen,  or  dashing  water  smartly 
on  it  from  a  cloth.  If  the  placenta  be  still  retained,  it  is  to  be  slowly 
detached,  and  after  keeping  it  and  the  hand,  for  some  time,  in  the 
Under  part  of  the  womb,  both  may  be  withdrawn.  No  remedy 
whatever  can,  in  my  opinion,  be  depended  on,  so  certainly  as  the 
introduction  of  the  hand,  and  in  no  case  ought  it  ever  to  be  ne- 
glected. I  will  not  go  the  length  of  saying,  that  it  is  infallible  in  its 
effects  ;  but  I  can  say,  that  if  it  fail,  I  believe  nothing  could  suc- 
ceed. I  have  met  with  most  obstinate  and  alarming  cases,  but  I 
never  yet  have  lost  a  patient,  from  uterine  hemorrhage  after  deli- 
very, when  I  attended  from  the  first ;  and  I  attribute  this  entirely 
to  the  prompt  introduction  of  the  hand. 

When  it  happens  that  part  of  the  placenta  adheres  pretty  firmly 
to  the  uterus,  we  are  not  to  be  rude  in  our  attempts  to  separate  it, 
but  should  remember  that  there  can  be  no  danger  in  being  deli- 
berate. It  is  too  much  the  practice  with  some  midwives,  to  trust 
more  to  their  fingers  than  to  the  contraction  of  the  uterine  fibres ; 
the  consequence  of  which  is,  that  they  tear  the  placenta,  and  irri- 
tate the  womb.  Yet  it  is  certain,  on  the  other  hand,  that  gentle  at- 
tempts to  separate  it  are  sometimes  necessary ;  but  these  should  be 
so  cautiously  and  deliberately  made  as  not  to  lacerate  the  placenta. 
The  fingers  should  be  very  slowly  and  gently  insinuated  betwixt 
the  uterus  and  the  placenta,  so  as  to  overcome  the  adhesion,  which 
is  seldom  extensive.  I  have  known  the  placenta  retained,  for  four 
days,  by  an  adhesion  not  larger  than  a  shilling.  This  case  proved 
fatal  by  loss  of  blood,  which  continued  to  take  place,  I  understand, 
in  variable  quantity,  during  the  whole  time.  No  attempts  were 
ttiade  to  relieve  the  woman  until  she  was  dying. 

We  can  in  general  save  the  patient  in  flooding,  if  we  are  on  the 


509 

spot  when  it  happens;  but  if  much  blood  have  been  lost  before  we 
arrive,  the  strength  may  be  irreparably  sunk.  In  those  cases  where 
great  weakness  has  been  produced,  we  must  not  only  endeavour  to 
excite  the  uterine  contraction,  in  order  to  prevent  further  injury, 
but  we  must  also  husband  well  the  power  which  remains.  The  hand 
is  to  be  immediately  introduced  into  the  womb,  and  must  be  kept 
there,  moving  it  gently,  until  the  fibres  contract;  and  until  this  takes 
place,  neither  the  hand  nor  the  placenta  should  be  withdrawn.  A 
cloth  moistened  with  cold  water  is  to  be  applied  suddenly  on  the 
abdomen;  pressure,  along  with  friction,  is  to  be  made  by  the  hand 
on  the  region  of  the  uterus,  and  the  whole  belly  firmly  supported 
with  a  bandage,  provided  that  can  be  applied  without  moving  the 
patient  much.  But,  as  every  exertion  is  dangerous,  motion  must 
be  avoided ;  and  upon  no  account  is  the  patient  to  be  shifted  or  dis- 
turbed, for  some  time.  By  imprudent  attempts  to  raise  the  pa- 
tient, or  "  to  make  her  more  comfortable,"  she  has  sometimes 
suddenly  expired. (t) 

The  state  of  the  stomach  is  to  be  watched,  preventing,  as  far  as 
we  can,  that  feeling  of  sinking  which  is  apt  to  take  place  in  all 
floodings.  This  is  to  be  done  by  keeping  up  the  action  of  that 
important  organ  with  soup,  properly  seasoned,  and  given  in  small 
quantity,  but  pretty  frequently  repeated.  Cordials,  as,  for  instance, 
jMadeira,  diluted  or  pure,  should  be  given  in  small  doses  regularly 
for  some  time,  to  support  the  strength ;  but  after  recovery  begins 
to  take  place,  and  the  pulse  steadily  to  be  felt,  they  should  be  omit- 
ted or  decreased  ;  for  if  persisted  in  to  the  same  extent,  fever  or 
inflammation  may  be  excited.  Opiates  are  of  greater  service  in  all 
cases  of  uterine  hemorrhage  after  delivery.  They  are  among  the 
safest  and  best  cordials  we  can  employ,  and  must  in  every  instance 
be  exhibited.  The  dose  ought  to  be  proportioned  to  the  urgency, 
varying  from  fifty  to  sixty  drops.  In  some  instances,  when  the 
debility  was  great,  a  hundred  drops  of  the  tincture,  or  when  the 
stomach  was  very  irritable,  five  grains  of  solid  opium,  have  been 

(i)  Le  Roy  thinks  the  position  of  the  patient  in  hemorrhages,  is  worthy  of 
consideration;  in  uterine  hemorrhage,  the  horizontal  position  of  course  must  he. 
preferred,  and  the  feet  should  be  more  elevated  than  the  head. 


510 

given  at  once,  and  afterwards  three  grains  every  three  hours,  till 
the  patient  was  out  of  danger.  Nor  does  this  practice  ever  prevent 
the  contraction  of  the  uterus,  or  produce  afterwards  any  bad  effect. 
Opiates  supply  the  place  of  wine,  and  are  infinitely  safer.  Aro- 
rnatics  have  been  given,  such  as  tincture  of  canella,  with  good  effect. 
Iced  water  has  also  been  recommended,  but  of  this  I  have  no  ex- 
perience. 

We  must  be  careful  neither  to  give  nourishment  nor  cordials  so 
frequently  as  to  load  the  stomach,  which  produces  sickness  and 
anxiety,  until  vomiting  remedy  our  error.  This  last  symptom, 
when  moderate,  is  not  always  unfavourable,  for  it  sometimes 
excites  more  powerfully  the  contraction  of  the  womb.  The  rising 
of  the  pulse,  and  relief  of  the  patient  after  it,  are  to  be  ascribed 
not  so  much  to  any  direct  power  which  this  operation  has  of  invigo- 
rating the  system,  as  to  the  consequent  removal  of  sickness  and 
oppression.  If  these  effects  do  not  follow  from  vomiting,  the  case 
is  very  bad.  Solid  opium  is  the  most  effectual  remedy  against  re- 
peated vomiting.  It  must  be  given  in  the  dose  of  at  least  three, 
and  in  some  cases,  four  grains. 

When  the  hemorrhage  has  produced  complete  syncope,  the 
-state  of  the  patient  is  very  alarming.  Yet  the  danger  is  not  the 
same  in  every  case,  for  some  women  faint  from  slighter  causes  than 
others.  La  Motte  relates  one  case  where  the  patient  fainted  no 
less  than  twenty  times,  in  the  course  of  the  night.  She  is  to  be 
preserved  in  a  state  of  the  most  perfect  rest,  the  face  is  to  be 
smartly  sprinkled  with  cold  water,  and  a  little  wine  or  brandy,  or 
spiritus  ammoniae  aromaticus,  given  after  the  opiate  already  exhi- 
bited, to  rouse  the  system.  Afterwards,  warm  spiced  wine  may 
be  given  in  small  quantity,  and  warm  cloths  applied  to  the  feet. 
Friction  on  the  region  of  the  stomach,  with  some  stimulating  em- 
brocation, as  hartshorn  and  spirits,  may  be  useful.  I  need  not  add, 
that  the  patient  must,  in  these  awful  circumstances,  be  carefully 
watched ;  and  that,  if  the  expression  be  allowed,  we  must  obsti- 
nately fight  against  death.  It  may  appear  to  some  that  stimulants, 
and  other  means  to  remove  syncope,  must  renew  the  hemorrhage, 
and  that  the  syncope  itself  is  useful,  by  checking  the  circulation. 
But  no  man  of  observation  can  suppose  syncope  to  be  safe,  in 


511 

hemorrhage  after  delivery,  or  hesitate,  by  opium  and  brandy,  oi 
wine,  to  recall  his  patient  to  animation,  or  prevent  a  renewal  of 
the  fainting  fits. 

It  was  at  one  time  the  practice  to  prevent  the  patient  from  sleep- 
ing, or  indulging  that  propensity  to  drowsiness  which  often  follows 
hemorrhage.  But  we  can  surely,  at  short  intervals,  give  whatever 
may  be  necessary  to  the  patient,  without  absolutely  preventing 
sleep,  or  rather  slumber,  for  the  patient  never  sleeps  profoundly. 
We  are  to  attend  so  far  to  the  advice,  as  not  to  allow  the  slumber 
to  interfere  with  the  administration  of  such  cordials  or  nourishment 
as  may  be  requisite. 

When  the  placenta  is  rashly  extracted,  immediately  after  the 
delivery  of  the  child,  or  suddenly  taken  away  upon  the  accession 
of  hemorrhage,  then  we  find  that  the  uterus  does  not  contract  pro- 
perly, and  the  vessels  pour  out  blood  plentifully.  This  in  part  es- 
capes by  the  vagina,  but  much  of  it  remains  in  the  cavity  of  the 
uterus,  where  it  coagulates,  and  hinders  the  free  discharge  of  the 
fluid  by  the  vagina.  But  blood  may  be  still  poured  out  into  the 
cavity  of  the  womb,  which  becomes  distended,  and  that  often  to  a 
great  size.  Thus  it  appears,  that  after  delivery  the  hemorrhage 
may  be  sometimes  apparent,  sometimes  concealed.  When  it  flows 
from  the  vagina,  it  is  always  discovered  by  the  patient;  but  when 
it  is  confined  in  the  uterus,  it  is  only  known  by  its  effects ;  the 
pulse  sinks,  the  countenance  becomes  pale,  the  strength  departs, 
and  a  fainting  fit  precedes  the  fatal  catastrophe. 

Even  when  the  placenta  has  not  been  rapidly  extracted,  hemorr- 
hage may  come  on,  and  most  frequently  it,  in  this  case,  proceeds 
from  rash  exertion,  or  much  motion.  In  an  uncivilized  state  of 
society,  we  find  that  almost  immediately  after  delivery,  the  parent 
is  able  to  walk  about ;  but  women  brought  up  in  the  European 
modes  of  life,  cannot  use  the  same  freedom.  Motion  not  only  dis- 
orders the  action  of  the  uterus,  and  impairs  its  contraction,  but  al- 
so powerfully  excites  the  circulation. 

The  continued  application  of  a  great  degree  of  heat,  mental  agi- 
tation, and  the  use  of  stimulants,  may  also  contribute  to  the  pro- 
duction or  renewal  of  hemorrhage. 

A  partial  or  complete  inversion  of  the  uterus  is  another  cause 


612 

of  hemorrhage,  and  which  can  only  be  discovered  by  examina- 
tion. 

Sometimes  a  partial  or  irregular  contraction  of  the  uterine  fibres 
takes  place,  and  the  person  is  tormented  by  grinding  pains,  accom- 
panied by  repeated  hemorrhage.* 

The  retention  of  a  small  portion  of  the  placenta,  which  has  firm- 
ly adhered  to  the  uterus,  is  also  a  cause  of  hemorrhage,  and  the 
discharge  may  be  renewed  for  many  days,  until  the  portion  be  ex- 
pelled. 

It  may  also  happen  that,  from  some  agitation  of  mind  or  morbid 
state  of  body,  the  uterus  may  not  go  regularly  on  in  its  process  of 
contraction  or  restoration ,f  to  the  unimpregnated  state.  In  this 
case,  the  cavity  may  be  filled  with  blood,  which  forms  a  coagulum, 
and  is  expelled  with  fluid  discharge.  The  womb  may  remain  sta- 
tionary, for  a  considerable  time,  and  the  coagula  be  successively 
expelled,  with  slight  pains,  and  no  small  degree  of  hemorrhage. 
These  symptoms  very  much  resemble  those  produced  by  the  re- 
tention of  part  of  the  placenta,  and  cannot  easily  be,  with  certainty, 
distinguished  from  them.  We  have,  however,  less  of  the  foetid 
smell,  and  we  never  observe  any  shreds  or  portion  of  the  placenta 
to  be  expelled,  whilst  the  coagulum,  if  entire,  has  exactly  the  shape 
©f  the  uterine  cavity. 

Lastly,  we  find,  that  if  exertion  have  been  used  before  the  ute- 
rus has  been  perfectly  restored,  there  may  be  excited  a  draining  of 
blood,  which  does  not  come,  in  general,  very  rapidly;  but,  from 
its  constant  continuance,  amounts  ultimately  to  a  considerable 
quantity,  and  impairs  the  health  and  vigour  of  the  woman.  This 
has  been  called  menorrhagia  lochialis. 

*  When  the  abdomen  has  been  bandaged  too  tightly,  the  parts  within  are  in- 
jured. The  patient  is  restless  and  uneasy;  the  pulse  is  frequent;  she  complains 
of  pain  about  the  uterus,  and  numbness  in  the  thighs.  Sometimes  the  lochia  are 
obstructed ;  sometimes,  on  the  contrary,  pretty  copious  hemorrhage  is  produced. 
Relief  is  obtained  by  slackening  the  bandage ;  by  giving  an  anodyne ;  and,  if 
there  be  no  hemorrhage,  by  fomenting  the  belly. 

I  This,  at  first,  is  owing  to  muscular  contraction  ;  afterwards,  absorption  forms 
part  of  the  process.  But  if  these  operations  shall  be  interrupted,  or  injured, 
then  the  vessels,  which  are  still  large,  not  being  duly  supported,  will  be  very  apt 
to  pour  out  blood. 


613 

When  hemorrhage,  whether  external  or  internal,  takes  place  hi 
mbderate  quantity,  immediately  after  the  expulsion  of  the  placenta, 
and  when  the  system  does  not  seem  to  suffer  materially,  we  may  he 
satisfied  with  firmly  supporting  the  uterus  hy  external  pressure, 
and  applying  a  dry  cloth  closely  to  the  orifice  of  the  vagina.  The 
blood  thus  coagulates  in  the  uterus,  which,  being  supported  by  the 
external  pressure  or  bandage,  does  not  distend,  and  the  action  of 
its  fibres  is  soon  excited.  After-pains  are  to  be  expected,  but  the 
fear  of  hemorrhage  is  removed.  In  some  instances,  when  we  have 
had  no  external  hemorrhage,  and  the  blood  has  been  slowly  pour- 
ed into  the  uterine  cavity,  little  inconvenience  is  produced  for 
some  time.  But  presently,  by  the  pressure  of  the  womb  on  the 
neck  of  the  bladder,  a  retention  of  urine  is  caused,  attended  with 
much  pain  in  the  belly.  This  is  in  general  instantly  removed,  by 
introducing  the  finger  into  the  vagina,  and  raising  up  the  uterus.  If 
it  should  not,  the  catheter  must  be  employed. 

But  whenever  hemorrhage  takes  place  to  such  an  extent  as  to 
endanger  the  patient,  and  produce  the  effects  1  have  already  men- 
tioned, then  we  must  interfere  more  actively  :  and  I  need  not  at- 
tempt to  prove,  that  the  only  security  consists  in  uterine  contrac- 
tion. This  is  to  be  excited  by  the  application  of  cold,  and  by  the 
introduction  of  the  hand,  not  simply  to  extract  the  coagula,  but  to 
stimulate  the  uterus,  and  rather  make  it  expel  them.  It  in  general 
will  be  found  that  the  uterus  is  affected  with  spasm.  Nothing  is  so 
useful  as  retaining  the  hand  for  some  time  in  the  lower  part  of  the 
uterus,  and  occasionally  gently  dilating  the  contracted  spot  above, 
at  the  same  time  that  we  rub  externally.  The  extraction  of  coa* 
gula  from  the  cavity  is  of  signal  benefit,  and  if  necessary  this  must 
be  done  oftenerthan  once.  Gardien  has  made  a  practical  remark, 
which  perfectly  agrees  with  my  experience,  that  the  successive 
emptying  of  the  uterus  is  the  best  remedy,  yet  this  must  not  be 
done  too  rapidly.  What  good  can  accrue  from  allowing  coagula 
to  remain?  It  cannot  prevent  the  farther  flow,  for  no  vessels  of 
such  size  as  the  uterine  can  be  slopped  in  this  way.  No  harm  can 
arise  from  their  removal ;  for  if  the  womb  do  not  contract,  and  the 
flow  continue,  we  re-introduce  the  hand,  and  are  at  least  as  well 
as  we  were  before.     We  must  also  proceed  with  opiates,  cordials, 

GG 


514 

and  nourishment,  upon  the  rules  formerly  stated  for  recovery  ;  and 
we  shall  do  well,  not  to  be  in  a  hurry  to  quit  our  patient,  for  the 
hemorrhage  may  be  renewed,  and  she  may  be  lost  before  we  can 
see  her. 

When  the  hemorrhage  proceeds  from  irregular  action  of  the  ute- 
rus, and  is  attended  with  grinding  pain,  a  full  dose  of  tincture  of 
opium  is  of  advantage,  and  seldom  fails  in  relieving  the  patient. 

If  the  placenta  have  been  torn,  and  a  portion  of  it  remain  attach- 
ed to  the  uterus,  the  hemorrhage  is  often  very  obstinate.  Both 
clotted  and  fluid  blood  will  be  discharged  repeatedly.  The  clot 
has  the  shape  of  the  uterus,  and  is  expelled  with  fluid  blood  like 
an  abortion.  An  offensive  smell  proceeds  from  the  uterus,  and  at 
last  the  portion  of  placenta  is  expelled  in  a  putrid  state,  after  the 
lapse  of  man)'  days,  or  even  weeks  ;  and  this  expulsion  is  often  at- 
tended with  severe  attack  of  hemorrhage.  By  examination,  the 
os  uteri  will  be  found  soft,  open,  and  irregular. 

If  by  the  introduction  of  the  finger  we  can  feel  any  thing  within 
the  uterus,  it  should  be  cautiously  extracted  ;  but  we  are  not  to  use 
force  or  much  irritation,  either  in  our  examinations  or  attempts  to 
extract,  lest  we  inflame  the  womb.  It  is  more  advisable  to  plug 
the  vagina,  and  even  the  os  uteri,  so  as  to  confine  the  blood,  and 
excite  the  uterine  contraction.  We  may  also  inject  some  cold  and 
astringent  fluid  for  the  same  purpose,  or  throw  a  full  stream  of  cold 
water  into  the  uterus,  from  a  large  syringe,  by  way  of  washing  out 
the  portion  of  placenta,  if  it  have  become  nearly  detached.  A 
gentle  emetic  sometimes  promotes  the  expulsion.  The  bowels 
are -to  be  kept  open,  and  the  strength  supported  by  mild  and  nou- 
rishing diet ;  but  we  must  take  care,  on  the  other  hand,  not  to  fill 
the  vessels  too  fast.  If  febrile  symptoms  arise,  the  case  is  still  more, 
dangerous,  as  I  will  presently  notice. 

When  the  hemorrhage  proceeds  from  an  interruption  of  the  pro- 
fess of  restoration,  our  principal  resource  consists  in  exciting  the 
contraction  of  the  womb  by  the  use  of  clysters — by  friction  on  the 
abdomen — by  injecting  cold  and  astringent  fluids  into  the  womb — 
by  the  exhibition  of  a  gentle  emetic — and  by  throwing  cold  wate* 
from  a  syringe  upon  the  abdomen,  when  the  womb  is  expelling 
the  coagulunu     We  also  check  the  hemorrhage,  and  save  blood,. 


615 

by  the  prompt  application  of  the  plug,  and  diminish  the  action  osl 
the  vessels  themselves,  by  allaying  or  removing  every  irritation, 
and  avoiding  the  frequent  use  of  stimulants,  or  attempts  to  fill  the 
vessels  too  quickly.  The  feeling  of  sinking,  sickness,  tendency  to 
syncope,  &:c.  are  to  be  obviated  by  the  means  already  pointed  out. 
Lastly  : — The  monorrhagia  lochialis  is  to  be  cured  by  rest,  cool 
air,  the  use  of  tincture  of  kino,  sulphuric  acid,  or  other  tonics, 
bathing  the  pubis  or  back  with  cold  water,  and  injecting  an  as- 
tringent fluid  three  or  four  times  a-day  into  the  uterus.  Some- 
times whenever  the  discharge  stops,  the  patient  complains  much  of 
stomachic  affection.  This  is  to  be  allayed  by  laxatives  and  aro- 
matics,  or  rubefacients  applied  to  the  epigastrium.  When  it  alter- 
nates with  diarrhoea,  confectio  catechu  is  useful,  along  with  some 
bitter  tincture.  If  the  pulse  be  frequent,  the  exhibition  of  digitalis 
for  a  short  time  will  be  of  advantage.  Pain  in  the  back  generally 
attends  this  disease,  and  is  sometimes  so  severe  as  even  to  affect 
the  breathing.  In  this  case,  a  warm  plaster  applied  to  the  back  is 
often  of  service  ;  and,  if  the  pulse  be  soft,  an  anodyne  should  be 
administered.  In  slight  cases,  the  application  of  cloths  dipped  in 
cold  vinegar,  to  the  back,  does  good. (7  J 

(~tj  The  acknowledged  efficacy  of  the  ergot,  in  increasing  the  energy  of" 
uterine  contractions,  would  appear  to  point  it  out  as  a  proper  remedy  to  be  had 
recourse  to  in  the  cases  of  hemorrhage  alluded  to  in  this  chapter ;  and  as  Dr. 
Bigelow  has  well  observed,  in  females  habitually  subject  to  profuse  hemorrhage? 
at  the  period  of  parturition,  there  is  perhaps  no  better  preventive  than  a  full 
dose  of  ergot,  administered  just  before  delivery.  The  editor  has  been  in  the 
practice  of  exhibiting  it  in  powder,  in  doses  of  a  scruple,  mixed  in  any  syrup  ; 
but  it  may  also  be  given  in  infusion  or  decoction  ;  for  instance,  a  drachm  of  the 
powder  may  be  infused  in  half  a  gill  of  boiling  water  and  a  table  spoonful  of  the 
turbid  fluid,  may  be  given  every  20  minutes,  till  its  effects  are  perceptible. 


51b' 

CHAP.  111. 

Of  Inversion  of  the  Uter-Ui. 

Inversion  of  the  uterus  implies,  that  the  inside  is  turned  out, 
and  down  into  the  vagina.  It  may  take  place  in  different  degrees, 
and  it  has  been  divided  accordingly  into  the  simple  depression  ; 
the  incomplete  inversion,  when  the  fundus  is  merely  engaged  in 
the  orifice  ;  and  the  complete,  when  it  protruded  out  of  the  vagina, 
and  exactly  resembled  the  uterus  after  delivery,  only  the  mouth 
turned  upward.  The  vagina  is,  in  this  case,  also  partly  reversed 
or  inverted,  so  that  the  tumour  is  of  considerable  length.  When 
it  is  partial,  the  tumour  is  retained  altogether,  or  chiefly  within 
the  vagina,  and  the  fundus  only  protrudes  to  a  certain  degree 
through  the  os  uteri,  forming  a  firm  substance,  something  like  a 
child's  head.*  When  the  uterus  is  inverted,  the  patient  feels 
great  pain,  generally  accompanied  with  a  bearing-down  effort,  by 
which  a  partial  inversion  is  sometimes  rendered  complete.  The 
pain  is  obstinate  and  severe,  she  feels  very  weak,  the  countenance 
is  pale,  the  pulse  feeble,  perhaps  nearly  imperceptible,  a  hemor- 
rhage very  generally  attends  the  accident,  and  often  is  most  pro- 
fuse. But  it  is  worthy  of  notice,  that  frequently  complete  inver- 
sion is  not  accompanied  with  hemorrhage,!  whilst  a  very  partial 

*  Mr.  White  of  Paisley  describe*-,  it  very  well,  as  resembling  a  printer's  ball . 
Med.  Com.  Vol.  XX.  p.  147.  Sometimes  it  does  not  pass  through  the  os  uteri., 
Denman,  II.  p.  351. 

Mangetus,  lib.  IV.  p.  1019,  relates  a  fatal  case,  where  the  tumour  was  taken 
for  the  head  of  a  second  child.  It  was  at  first  partially,  and  then  completely,  in- 
verted with  excruciating  pain. 

Mr.  Smith  relates  a  case  of  inversion,  where  the  accident  was  followed  by  syn- 
cope, subsultus,  &c.  The  subsultus  and  frequent  pulse  continued  for  some  days, 
with  smart  fever,  and  inability  to  move.  Med.  and  Phys.  Jour.  Vol.  VI.  p.  503. 
In  the  same  volume,  Mr.  Primrose  gives  an  instance  where  a  great  part  of  the 
uterus  sloughed  off,  and  the  woman  recovered. 

|  This  was  the  case,  in  the  instance  related  by  Dr.  Hamilton.  Med.  Com.  Vol. 
XVL  p.  315. — In  the  case  by  Mr.  Brown,  the  hemorrhage  was  considerable. 


517 

inversion  may  be  attended  with  a  fatal  discharge  ;  although  there 
be  little  hemorrhage,  the  face  is  pale,  and  the  pulse  weak  and 
rapid,  a  sensation  of  dragging  at  the  stomach  or  a  feeling  as  if  the 
bowels  were  pulled  out  of  the  belly,  may  accompany  inversion. 
Fainting,  and  convulsions,  are  not  unfrequent  attendants,  although 
the  hemorrhage  have  been  trifling.  Inversion  is  suspected  to  ex- 
ist from  the  symptoms  mentioned,  and  on  examination,  the  womb 
is  felt  more  or  less  protruded  like  a  mass  of  flesh,  whilst  no  hard 
uterus  can  be  discovered  in  the  hypogastrium. 

Inversion,  in  a  great  majority  of  instances,  depends  upon  the 
midwife*  endeavouring  to  extract  the  placenta,  by  pulling  the 
cord.(u)  Sometimes  the  uterus  is  directly  pulled  down,  and  the 
placenta  still  adheres;  in  other  cases  it  is  separated.  It  may  also 
happen,  if  the  child  be  allowed  to  be  rapidly  expelled  ;  for  if  the 
cord  be  short,  or  entangled  about  the  child,  the  fundus  may  receive 
a  sudden  jerk,  and  become  inverted.  From  the  same  cause,  or 
sometimes  perhaps  from  sudden  pressure  of  part  of  the  intestines 
on  the  fundus  uteri,  occasioned  by  strong  contraction  of  the  ab- 
dominal muscles,  a  part  of  the  fundus  becomes  depressed  like  a 
cup,  and  encroaches  on  the  uterine  cavity.  This  generally  recti- 
fies itself  if  let  alone  ;  but  if  the  cord  be  pulled,  or  if  there  be  any 
tendency  in  the  uterine  action,  to  go  toward  the  fundus,  as  happens 
when  that  part  is  lacerated,  and  may  in  like  manner  occur  in  the 


Annals  of  Med.  Vol.  Jf .  p.  277.    I  have  seldom  seen  much  hemorrhage  attend 
complete  inversion. 

•  Chapman  relates  a  case  of  inversion,  where  the  midwife  pulled  forcibly  at 
the  uterus,  and  excited  convulsions,  fainting',  and  death.    Case  29,  p.  123. 

fvj  Or  probably,  by  pulling-  at  the  cord  before  that  contraction  of  the  uterus 
which  is  to  expel  the  placenta  from  its  cavity,  takes  place  : — hence  may  be  de- 
duced a  general  rule  worthy  of  the  attention  of  young  practitioners,  to  wait,  af- 
ter ",the  delivery  of  the  child,  until  the  woman  complains  of  pain,  (which  gene- 
rally indicates  the  contraction  of  the  uterine  fibres)  before  they  attempt  to  co- 
operate in  the  extraction  of  the  placenta,  and  even  then  to  act  with  caution. 

An  exception  may  nevertheless  occur  to  this  rule  to  be  noticed  here,  viz.  that 
sometimes  the  same  contraction  that  expels  the  child,  may  detach  the  placenta, 
and  propel  it  into  the  cervix  uteri  and  vagina  ;  this  is  to  be  determined  by  ex- 
amination;  a.nd  if  found  to  be  the  case,  we  proceed  to  immediate  extraction- 


518 

present  case,  the  depression  is  speedily  converted  into  perfect  in- 
version. It  is  in  this  way  that  we  are  to  account  for  those  cases 
which  have  apparently  taken  place  many  days  after  delivery,  and 
where,  either  with  or  without  hemorrhage,  the  uterus  has  sudden- 
ly come  down.  It  would  appear,  however,  that  this  depression  of 
the  fundus,  ending  at  last  in  complete  inversion,  may  take  place 
some  time  after  delivery.  There  is  one  case  of  this  kind  record- 
ed, when,  on  account  of  hemorrhage,  the  hand  had  been  introduc- 
ed, and  the  uterus  was  not  found  unusual  in  its  figure.  On  the 
J  2th  day  inversion  took  place.  Even  in  this  instance,  however, 
it  is  by  no  means  certain  that  there  was  no  depression  early  ;  for 
the  practitioner,  Ane,  might  not  have  attended  minutely  to  this 
circumstance,  not  expecting  it.  An  incomplete  inversion  may  re- 
main for  life,  and  occasion  incurable  fluor  albus  and  hemorrhage. 
Some,  however,  speculate  on  a  cure  being  effected  by  pregnancy, 
which  doubtless  would  be  the  case  if  that  could  take  place. 

It  has  been  supposed  possible,  that  inversion  might  take  place 
in  the  virgin  state,  if  the  womb  had  been  distended  by  blood  or 
other  fluid. 

Inversion  may  terminate  in  different  ways.  It  may  prove  rapid- 
ly fatal  by  hemorrhage  ;  or  it  may  excite  fatal  syncope,  or  con- 
vulsions ;  or  it  may  operate  more  slowly,  by  inducing  inflamma- 
tion, or  distention  of  the  bladder  ;  or  after  severe  pains  and  expul- 
sive efforts,  the  patient  may  get  the  better  of  the  immediate  inju- 
ry, the  uterus  may  diminish  to  its  natural  size,  by  slow  degrees, 
and  give  little  inconvenience  ;*  or  it  may  discharge  foetid  matter, 
and  give  riscto  frequent  debilitating  hemorrhage,  with  bopious  mu- 
cous discharge  in  the  intervals  ;  or  hectic  comes  on,  and  the  pa- 
tient sinks  in  a  miserable  manner.  It  has  also  been  said,  that  af- 
ter a  lapse  of  many  years,  the  inversion  might  be  spontaneously 
cured,  which  Dailliez  explains,  by  supposing  that  the  tubes  pull  up 

*  La  Motte,  383,  mentions  a  woman  who  had  inversion  for  above  thirty 
years.  Dr.  Cleghorn,  Med.  Comraun.  II.  226,  relates  a  case  where  the  uterus 
slowly  returned  to  its  natural  size.  This  woman  still  menstruates,  and  enjoys 
tolerable  health  ;  it  has  been  of  twenty  years  standing-.  The  womb  is  smooth, 
moist,  and  gives  little  pain.  Menstruation  also  continued  in  Dr.  Hamilton's  case, 
Com.  XVI.  p.  315. 


519 

the  inverted  part.  There  are  two  examples  of  this  termination  re- 
corded, and  one  of  them  (Mad.  Bourchalatte,)  on  the  authority  of 
the  justly  celebrated  Baudelocquc.*  In  this  case  the  restoration 
took  place,  after  a  lapse  of  eight  years.  If  this  be  physically  pos- 
sible, it  must  at  least  be  exceedingly  rare. 

If  inversion  be  discovered  early,  the  uterus  may  he  replaced. 
If  it  have  protruded  out  of  the  vagina,  it  is,  first  of  all  to  be  return- 
ed within  it ;  if  it  have  not,  we  proceed  directly  to  endeavour  to 
return  it  within  the  os  uteri,  by  cautiously  grasping- the  tumour  in 
the  hand  and  pushing  it  upwards,  within  the  os  uteri.  This  may 
be  facilitated  by  pressing  up  the  most  prominent  part  of  the  fun- 
dus in  the  direction  of  the  axis  of  the  uterus,  so  as  gradually  to  un- 
do the  inversion,  or  re-invert  the  protruded  womb  :  a  piece  of 
wood  with  a  round  head  has  by  some  been  used  in  this  way  ;  but 
the  fingers  are  safer.  If  we  push  directly  without  compressing 
the  tumour,  we  sometimes  bring  on  violent  bearing-down  pains. 
These  are  occasionally  attended  with  increase,  or  renewal,  of  flood- 
ing, and  in  all  cases  on  pressing  the  uterus,  small  vessels  spout 
like  arteries  in  an  operation.  If  we  succeed,  we  should  carry  the 
hand  within  the  uterus,  and  keep  it  there  for  some  time,  to  excite 
Its  contraction.  If  the  placenta  still  adhere,  we  should  not  remove 
it  until  we  have  reduced  the  uterus ;  after  which,  we  excite  the 
contraction  of  the  womb  to  make  it  throw  it  ofF.-j-  It  is  sometimes 
long  before  the  pulse  becomes  steadily  to  be  felt.J  Occasionally, 
after  the  reduction,  when  the  patient  is  seeming  to  do  well,  she  is 
seized  with  a  fit  and  dies.vs  Or,  she  may  remain  long  weak,  and 
have  swelled  feet.(| 

If  inversion  have  not  been  discovered  early,  it  is  more  difficult, 
nay,  sometimes  impossible  to  reduce  it,  owing  chiefly  to  contrac-- 

*  Gardien,  Traite,  Tom.  III.  p.  335. 

f  In  a  case  related  in  Memoirs  of  Med.  Soc.  Vol.  V.  202,  the  placenta  wasaK 
towed  to  remain  five  days  after  reduction,  but  this  is  a  hazardous  practice. — Per- 
fect, case  71,  brought  it  away  after  four  hours. 

*  Case  by  Dr.  Duffield,  in  Trans,  of  Coll.  at  Phil.  16r. 
§  Case  by  Dr.  Albers.  Annals  of  Med.  Vol.  V.  390. 

I  Mr.  White's  case,  Med.  Comment.  Vol.  XX.  24,7: 


520 

tion  of  the  os  uteri,  (x)  Dr.  Denman  says,  that  he  has  found  it  im- 
possible to  reduce  it,  even  four  hours  after  it  took  place  :  and  in  a 
chronic  inversion,  he  never  once  succeeded.  In  such  cases,  it  is 
not  prudent  to  make  very  violent  efforts  to  reduce  the  uterus,  as 
these  may  excite  convulsions,  &ic.  Soon  after  becoming  inverted, 
the  uterus  is  apt  to  swell  and  inflame.  If  this  have  happened,  no 
attempt  should  be  made  to  reduce,  till  by  bleeding,  and  rest,  and 
mild  fomentations,  this  state  have  been  allayed.  We  must  in  every 
instance  alleviate  urgent  symptoms,  such  as  syncope,  retention  of 
urine,  or  inflammation,  by  suitable  means.  I  may  further  observe, 
that  when  a  patient,  after  delivery,  complains  of  obstinate  pain,  or 
bearing  down,  or  suppression  of  urine,  or  is  very  weak,  we  should 
always  examine  per  vaginam.  If  the  uterus  be  inverted,  we  may 
feel  the  tumour,  and  we  may  find  the  hard  womb  to  be  absent  in 
the  belly,  or  lower  down  than  it  should  be.  If  this  examination  be 
neglected,  the  patient  may  be  lost.  I  have  known  the  first  inti- 
mation given  to  the  practitioner,  to  be  his  finding  no  uterus  in 
the  belly,  when  it  was  opened  after  cleadi.  Examination  is  of  the 
utmost  consequence. 

When  the  uterus  cannot  be  replaced,  we  should  at  least  return  it 
into  the  vagina.  We  must  palliate  symptoms,  apply  gentle  astrin- 
gent lotions,  keep  the  patient  easy  and  quiet,  attend  to  the  state  of 
the  bladder,  support  the  strength,  allay  irritation  by  anodynes,  and 
the  troublesome  bearing  down  by  a  proper  pessary;  the  bad  effects 
of  neglecting  or  removing  this  are  to  be  seen  in  La  Motte's  385th 
case.  A  spring  bandage  is  also  useful.  If  inflammation  come  on, 
as  is  usually  the  case,  we  must  prescribe  blood-letting,  laxatives, 
&c.  In  this  way,  the  uterus  contracts  to  its  natural  size,  and  the 
woman  menstruates  as  usual,  but  generally  the  health  is  delicate. 

(.r)  In  cases  of  parted  inversion,  where  it  has  been  found  impracticable  to 
reduce  the  uterus,  it  lias  been  advised  to  grasp  the  portion  which  has  passed 
through  the  06  uteri  firmly  with  the  hand,  and  render  the  inversion  complete, 
by  bringing  the  whole  of  the  uterus  into  the  vagina,  aud  keeping  it  there.  By  this 
means,  the  danger  of  strangulation  from  the  stricture  occasioned  by  the  contrac- 
tion of  the  os  uteri  on  the  body  of  that  viscus,  is  presumed  to  be  prevented. 
This  plan  appears  to  have  succeeded  in  a  case  related  by  Dr.  Dewees,  in  tit' 
"Philadelphia  Medical  Museum,  Vol.  VI.  p.  20.  and  seq.  Case  2d. 


521 

Sometimes  the  uterus  becomes  scirrhous,  or  gangrenous  sloughs 
take  place.* 

If  the  uterus  discharge  foetid  matter,  and  hemorrhage  take  place, 
the  strength  is  apt  to  sink,  and  the  patient  dies  hectic.  Astringent 
applications,  with  attention  to  cleanliness,  good  diet,  and  the  occa- 
sional use  of  opiates  may  give  relief;  but  if  they  do  not,  we  are 
warranted  to  prefer  extirpation  of  the  uterus  to  certain  death. 
This  operation  has  been  repeatedly  successful,!  and  is  performed 

*  Schmucker's  Surgical  Essays,  Art.  xvii. — A  case  is  given,  Med.  Journ.  VI. 
367,  where  appearance  of  gangrene,  from  strangulation,  took  place.  The  womb 
was  scarified,  and  the  swelling  quickly  disappeared.    The  patient  recovered. 

f  The  inverted  uterus  has  been  torn  off  with  the  crotchet,  being  mistaken  for 
the  child's  head.  Jour,  de  Med.  Tom.  XLI.  p.  40.  A  case  of  successful  extir- 
pation is  inserted  in  the  same  work  for  August  1786.  Wrisberg  relates  a  case, 
where  it  was  cut  off  by  the  midwife,  who  had  inverted  it.  A  successful  case  is 
given  by  Dr.  Clarke,  in  Edin.  Med.  and  Surg.  Jour.  Vol.  II.  p.  419.  Another  case 
is  mentioned  in  the  Recueil  des  Actesde  laSociete  deLyon.  Petit  of  Dijon  says, 
a  surgeon,  by  mistake,  applied  the  ligature  and  cured  the  woman.  The  surgeon's 
son  denies  that  the  cure  was  wrought  by  mistake.  Osiander  relates  a  case  where 
the  midwife  pulled  down  the  uterus  and  placenta,  and  cut  them  both  away.  The 
patient  recovered,  and  afterwards  was  exhibited  during  every  course  of  lectures. 
Mr.  Hunter  of  Dumbarton  gives  a  successful  case,  in  Annals  of  Med.  Vol.  IV.  366. 
1  have  particularly  examined  this  woman,  several  years  after  the  operation.  She 
was  delivered  without  any  violence,  after  having  been  twenty -four  hours  in  la- 
bour. In  about  an  hour  the  placenta  came  away.  She  had  considerable  flooding 
and  great  weakness.  She  could  not  void  her  urine,  which  in  two  days  was  drawn 
off  with  the  catheter,  and  this  was  frequently  repeated.  A  fortnight  after  deli- 
very, the  womb  came  down  with  pains.  It  was  replaced,  but  again  came  down. 
A  foetid  discharge  took  place,  and  the  woman  was  reduced  to  a  state  of  great 
weakness.  A  ligature  was  applied,  which  she  says,  gave  her  a  good  deal  of  pain, 
and  the  tumour  was  cut  off.  Her  account  differs  in  some  respects  from  Mr.  Hun- 
ter's, probably  owing  to  her  speaking  from  memory  alone,  some  years  after  the 
event ;  and  she  does  not  notice  the  previous  extraction  of  any  lumps  from  the 
uterus,  which  Mr.  Hunter  mentions,  for  most  likely  she  did  not  know  of  that. 
About  two  years  ago,  she  had  for  a  length  of  time  a  discharge  of  thick  white  mat- 
ter. At  present,  the  vagina  is  of  the  usual  length  ;  and  at  the  top  a  transverse 
aperture  is  felt,  the  posterior  lip  or  edge  of  which  is  longer  and  more  tendinous 
to  the  feel,  than  the  anterior.  It  admits  the  tip  of  the  finger,  and  feels  softer 
than  the  os  uteri,  in  a  natural  state.  There  is  no  cervix  uteri.  The  mammae  are 
firm,  and  of  good  size,  and  she  has  not  lost  the  sexual  desire.  She  is  subject  to 
dyspepsia.  From  the  preparation  in  the  possession  of  Dr.  Jeffray,  there  can  hjs 
little  doubt  that  part  of  the  uterus  was  extirpated. 

07 


522 

by  applying  a  ligature  high  up,  and  cutting  off  the  tumour  below. 
But  it  must  also  be  remembered,  that  in  some  cases  where  the  in- 
verted litems  has  been  either  intentionally  extirpated,  or  mistaken 
for  a  polypus,*  death  has  followed. 

Inversion,  when  long  continued,  may  be  confounded  with  pro- 
lapsus, or  polypus :  from  the  first,  it  is  distinguished  by  the  shape 
and  by  the  absence  of  the  os  uteri ;  from  the  second,  by  attending 
to  the  history,  and  by  careful  examination.  In  complete  inversion, 
there  may  be  a  rugous  state  or  corrugation  at  the  top,  but  can  be 
no  distinct  orifice,  as  in  polypus.  A  polypus  is  more  moveable, 
especially  more  capable  of  being  rolled.  It  is  generally  of  a  dif- 
ferent shape,  being  more  bulging  at  the  extremity  and  having  a 
smaller  pedicle,  and  the  finger  can  be  carried  as  far  as  it  can  reach 
within  the  os  uteri,  which  embraces  it  more  like  a  ring  than  a 
mouth  with  projecting  lips.  It  is  quite  insensible,  yet  we  must  re- 
member, that  pressing  it  may  press  the  uterus  and  cause  sensation; 
but  scratching  or  irritating  it  does  not  give  pain.  Still  there  may 
be  cases  where  some  doubt  remains.f 

Mr.  Newnham,  in  his  Treatise  on  Inversion,  p.  31,  relates  the  case  of  Mrs. 
Glasscock,  who  had  a  ligature  applied  to  the  inverted  uterus,  but,  on  account  of 
pain,  it  was  removed  in  some  hours.  As  she  was  evideutly  losing  ground,  it  was 
re-applied  on  the  13th  of  April.  It  produced  much  pain,  which  came  at  intervals, 
like  that  of  labour.  This  was  allayed  by  opiates,  and  the  ligature  gradually  tight- 
ened. She  was  very  irritable,  and  suffered  much  from  spasmodic  pain  ;  but,  on 
the  6th  of  May,  the  tumour  dropped  oft'  and  she  got  well.  As  the  finger  could 
be  passed  within  the  os  uteri,  and  around  the  tumour,  the  inversion  must  have 
been  incomplete.  The  inverted  uterus,  when  touched  with  the  finger,  appeared 
to  be  nearly  insensible,  and  had  never  caused  pain. 

Bartholin  relates  a  case,  where  the  inverted  womb  was  torn  away,  and  found 
under  the  bed  of  the  dead  patient. — Blasius,  a  case,  where  the  uterus  was  hard 
and  scirrhous;  it  was  tied,  but  on  the  third  day  the  patient  died.  In  the  cavity 
of  the  portion  were  found  the  ovaria  and  ligaments. — Goulard's  patient  died  on 
the  18th  clay.  Mem.  of  Acad,  de  Sciences,  1732.  The  uterus  has  also  been 
successfully  extirpated,  partly  by  the  ligature,  partly  by  the  scissors,  by  Mr. 
Windsore.     Med.  Chir.  Trans.  Vol.  X.  p.  358. 

*  In  a  case  related  in  Uecueil  des  Actes  de  la  Societc  de  Sante  de  Lyon,  the 
uterus  was  taken  for  polypus,  and  the  ligature  applied.  The  mistake  being  dis- 
covered, it  was  instantly  withdrawn,  but  the  woman  died  in  a  few  days. 

f  In  one  case  the  os  uteri  adhered  to  the  neck  of  the  polypus,  and  gave  rise  to 
appearance  of  inverted  uterus.    Mem.  of  Med.  Soc.  Vol.  V.  p.  11. 


523 

An  incomplete  inversion  is  more  apt  to  be  mistaken,  for  the  fin- 
ger can  be  passed  within  the  os  uteri,  and  along  what  appears  to 
be  the  stalk  or  pedicle  of  a  polypus;  but  this  root  is  thicker  than 
in  the  polypus,  and  the  os  uteri  is  somewhat  thickened  and  pro- 
jecting. The  tumour  itself  is  not  very  sensible,  but  nevertheless 
may  be  distinguished  from  polypus  by  scratching  it  gently  with  a 
sharp  probe,  which  will  cause  some  sensation,  whilst  in  the  poly- 
pus it  causes  none  unless  we  move  it,  and  thereby  move  the 
womh.(y) 


CHAP.  IV. 

Of  After-pains.. 

Few  women  proceed  through  the  early  part  of  the  puerperal  state, 
without  feeling  attacks  of  pain  in  the  belly,  which  are  called  after- 
pains.  These  are  generally  least  severe  after  a  first  labour.  They 
proceed  from  the  contraction  of  the  uterus  in  an  irregular  manner, 
excited  by  the  presence  of  coagula,  or  other  causes,  and  each  se- 
vere pain  is  generally  followed  by  the  expulsion  of  a  clot.  They 
come  on  usually  very  soon  after  delivery,  and  last  for  a  day  or  two. 
They  are  often  increased,  when  the  woman  first  applies  the  child 
to  the  breast.  They  are  distinguished  from  inflammation  of  the 
uterus  or  peritoneum,  by  remitting  or  going  off.  The  belly  is  not 
painful  to  the  touch,  the  uterine  discharge  is  not  obstructed,  the 
patient  has  no  shivering  nor  vomiting,  the  milk  is  secreted,  and  the 


fvj  Inversion  of  the  uterus  may  be  occasioned  by  the  weight  of  an  excres- 
cence of  the  nature  of  polypus,  depending  from  the  fundus  of  the  uterus. — 
For  a  case  of  this  kind,  together  with  an  illustrative  plate,  see  Denman's  Collec- 
tion of  Engravings,  tending  to  illustrate  the  generation  and  parturition  of  ani- 
mals, and  of  the  human  species. 

The  fundus  of  the  uterus  was  completely  inverted,  and  dragged  through  the 
os  uteri  into  the  vagina.    This  case  is  worthy  of  consultation. 


524 

pulse  is  seldom  frequent.  When  the  pulse  is  frequent,  then  we 
must  always  be  on  our  guard :  for  if  this  be  the  case  before  the  ac- 
cession of  the  milk-fever,  the  patient  is  not  out  of  danger,  and  if 
any  other  bad  symptom  appear,  we  must  be  prompt  in  our  prac- 
tice. After-pains  may  also  be  caused  by  flatulence  and  costive- 
ness,  which  we  know  by  the  usual  symptoms  ;  but  a  combination 
of  this  state  with  uterine  after*pains  is  often  attended  with  a  fre- 
quency of  the  pulse,  and  may  give  rise  to  a  fear  that  inflammation 
is  about  to  come  on,  but  other  symptoms  are  absent.  Uterine  af- 
ter-pains are  relieved  by  opiates,^  friction,  and  fomentations,  and 
these  are  the  usual  remedies ;  but  if  protracted,  or  very  severe,  the 
spasmodic  action  which  causes  them,  is  more  readily  and  effectu- 
ally removed,  by  a  purgative  than  by  opium.  This  fact  I  first 
learned  by  accident.  If  the  pulse  be  frequent,  this  is  indispensible. 
A  severe  constant  pain  in  the  hypogastric  region  is  sometimes  pro- 
duced by  an  affection  of  the  heart,  and  proves  fatal,  yet  the  ute- 
rus is  found  healthy. 

Upon  this  subject,  it  may  not  be  improper  to  mention,  that  a. 
young  practitioner  may  mistake  spasmodic  affections  or  colic  pains 
for  puerperal  inflammation ;  for  in  such  cases  there  is  often  retch- 
ing and  sensibility  of  the  muscles,  which  renders  pressure  painful. 
But  there  is  less  heat  of  the  skin,  the  tongue  is  moist,  the  pulse, 
though  it  may  be  frequent,  is  soft,  the  feet  are  often  cold,  the  pain 
has  great  remissions  if  it  do  not  go  off  completely,  there  is  little 
fulness  of  the  belly,  and  the  patient  is  troubled  with  flatulence.  It 
requires  laxatives,  antispasmodics,  anodyne  clysters,  and  friction 
with  camphorated  spirits.  Oil  of  turpentine  acts  both  as  a  laxa- 
tive and  antispasmodic.  In  doses  of  half  an  ounce,  it  often  relieves 
spasmodic  pain  in  the  stomach  or  bowels ;  but  in  this  case,  it  is 
better  to  combine  it  with  castor  oil,  giving  two  drams  of  the  former 

(~zj  It  is  frequently  necessary  to  give  the  opiate  in  pretty  large  doses,  and 
repeat  it  every  few  hours  ;  as  for  instance,  2  grains  of  purified  opium,  or  50  or 
60  drops  of  laudanum  ;  where  these  fail,  the  best  effects  are  sometimes  experi- 
enced from  an  enema  of  80  or  100  drops  of  laudanum,  in  four  table-spoonfuls  of 
thin  starch,  or  infusion  of  flaxseed.  When  these  do  not  succeed,  the  strong  in- 
fusion  or  tincture  of  hops  may  be  tried,  or  camphor  and  opium  combined,  givea 
by  the  mouth. 


525 

and  four  of  the  latter.  Blood  drawn  in  this  disease,  after  it  hag 
continued  for  some  hours,  even  when  the  woman  is  not  in  child- 
bed, is  sizey  ;  and  it  is  always  so  in  the  puerperal  as  well  as  the 
pregnant  state,  although  the  woman  be  well.  The  external  appli- 
cation of  oil  of  turpentine  is  also  useful. 

It  is  necessary  to  attend  carefully  to  the  duration  and  situation  of 
pain  after  delivery,  and  to  the  symptoms  connected  with  it.  For 
it  may  proceed  from  inflammation  of  the  viscera  ;  or  in  some  cases 
it  is  felt  near  the  groin,  and  may  be  the  forerunner  of  swelled  leg ; 
or  about  the  hip,  ending  in  a  kind  of  rheumatic  lameness  ;  or  in 
consequence  of  the  application  of  cold,  pain  may  be  felt  in  some 
part  of  the  recti  or  oblique  muscles,  which,  if  not  removed  by 
fomentations  and  frictions,  may  end  in  abscess,  which  frequently  is 
long  of  bursting,  and  excites  hectic  fever.  It  ought  to  be  opened 
with  a  lancet. 

Rheumatism,  affecting  the  muscles  of  the  abdomen  and  pelvis, 
is  accompanied  with  less  fever  than  puerperal  inflammation,  and 
wants  the  other  symptoms.  The  pain  is  shifting  and  aching,  or 
gnawing,  though  sometimes  it  is  pretty  sharp,  like  a  stitch.  It  is 
relieved  by  friction,  with  laudanum,  by  sinapisms,  and  by  mild  dia- 
phoretics, bark,  and  the  usual  treatment.  When  speaking  of  rheu- 
matic pain,  it  may  not  be  improper  to  mention,  that  chronic  rheu- 
matism, especially  of  the  extremities,  is  very  troublesome  when  it 
occurs  after  parturition.  It  requires  the  usual  remedies.  Cod- 
liver  oil,  in  doses  of  half  an  ounce,  three  times  a-day,  has  been 
much  recommended.  I  have  formerly  noticed  those  pains  ifl  the 
limbs  which  may  succeed  the  use  of  the  crotchet. 


CHAP.  V. 

Of  Hysteralgia. 

By  hysteralgia,  I  understand  uterine  pain  proceeding  from  spasm,- 
and  not  from  inflammation.     This  may  occur  soon  after  delivery, 


526 

and  is  marked  by  severe  pain  in  the  back  and  lower  belly,  frequent 
feeble  pulse,  sickness,  and  faintness.  This  is  sometimes  accom- 
panied with  discharge,  or  succeeded  by  expulsion  of  a  coagulum. 
It  requires  a  purgative  clyster  immediately,  and  afterwards  an  opi- 
ate; or,  if  it  occur  very  early  after  delivery,  we  may  reverse  the 
practice,  and  give  instantly  an  anodyne  clyster,  to  be  followed  by  a 
purgative  medicine  if  the  stomach  will  bear  it.  Another  modifi- 
cation of  this  comes  on  later,  but  always  within  three  or  four  days 
after  delivery,  and  attacks  in  general  very  suddenly.  Perhaps  the 
patient  has  risen  to  have  the  bed  made,  becomes  sick,  or  vomits, 
and  is  seized  with  violent  pain  in  the  lower  part  of  the  belly,  or 
between  the  navel  and  pubis.  There  is  no  shivering,  at  least  it  is 
not  a  common  attendant,  and  the  pulse  becomes  very  rapid,  being 
sometimes  above  a  hundred  and  twenty,  the  skin  is  hot,  the  lochia 
usually  obstructed,  and  the  uterine  region  is  somewhat  painful  on 
pressure.  After  some  hours  the  severity  abates,  and  presently  by 
proper  means  the  health  is  restored. 

As  the  lochial  discharge  is  usually  obstructed,  this  obstruction 
has  been  considered  as  the  cause  of  the  pain  and  other  symptoms; 
but  it  is  merely  an  effect,  and  sometimes  does  not  exist.  The 
cause  appears  to  consist  in  a  deranged  state  of  action  in  the  ute- 
rus, which  is  productive  of  spasm  of  the  uterine  fibres,  and  some- 
times of  the  intestines.  This  is  more  apt  to  occur  after  a  severe 
or  tedious,  than  after  an  easy  labour,  but  it  may  occur  in  any  case, 
especially  if  exposed  to  cold.  The  symptoms  will  vary  a  little  in 
severity  and  in  appearance,  according  as  the  uterus  alone  is  affect- 
ed, or  as  spasm  of  the  bowels  is  combined  with  the  uterine  pain. 
It  is  distinguished  from  inflammation  by  the  sudden  nature  of  the 
attack,  the  absence  of  shivering  iiv  general,  the  pain  becoming 
speedily  more  severe  than  it  does  at  the  same  period  of  inflamma- 
tion; and  frequently  it  greatly  remits,  or  goes  almost  entirely 
away  for  a  short  time.  It  is  possible,  however,  for  this  state,  espe- 
cially if  it  be  neglected,  to  excite  inflammation,  which  is  marked 
by  constant  pain,  more  or  less  severe  according  to  the  part  affect- 
ed, and  an  obstinate  continuance  of  the  fever. 

The  first  thing  to  be  done,  is  to  administer  a  turpentine  clyster 
to  open  the  bowels.    Then  the  belly  is  to  be  fomented,  and  if 


527 

speedy  relief  be  not  obtained  by  these  means,  an  anodyne  injec- 
tion is  to  be  given,  and  the  saline  julap  is  to  be  taken  freely,  with 
the  addition  of  a  little  antimonial  wine,  in  order  to  excite  a  free 
perspiration.  If  the  symptoms  continue,  I  strongly  advise  the  de- 
traction of  blood.  Purgatives  are  useful,  and  a  cloth  soaked  in  oil 
of  turpentine  must  be  applied  to  the  pained  part  of  the  belly,  to 
prevent  inflammation. 


CHAP.  VI. 

Of  Retention  of  part  of  the  Placenta. 

If  either  the  whole,  or  a  considerable  portion  of  the  placenta, 
be  left  in  utero  for  some  time,  the  patient  is  exposed  to  great  dan- 
ger. Hemorrhage  is  not  the  only  risk,  for  in  many  cases  severe 
headach,  hysterical  affections,  sickness,  nausea,  prostration  of 
strength,  and  fever  have  taken  place,  and  continued  until  the  pla- 
centa have  been  expelled,  after  which  the  patient  has  begun  to  re- 
cover. On  the  other  hand,  it  has,  though  more  rarely,  occurred, 
that  the  placenta,  having  been  retained  for  a  length  of  time,  has 
been  expelled  before  these  symptoms  have  become  urgent;  but 
they  have  afterwards  gradually  increased,  and  carried  off  the  pa- 
tient.* Sometimes  the  symptoms  run  so  high,  or  the  portions  of 
the  placenta  are  so  obstinately  retained,  that  the  patient  sinks  un- 
der the  disease,  as  in  ordinary  cases  of  hectic,  with  frequent  small 
pulse,  burning  heat  of  the  hands  and  feet,  profuse  perspirations, 
and  universal  emaciation ;  or  dies  with  symptoms  similar  to  those 
of  putrid  fever ;  or  is  carried  off  suddenly  by  a  convulsion,  or  an 
attack  of  hemorrhage. 

*  In  a  case  related  by  Mr.  Whyte,  the  secundines,  after  a  clyster,  came  away 
in  a  putrid  state  on  the  fifth  day.  On  the  sixth,  the  patient  was  much  oppressed, 
had  foetid  breath,  &c.  on  the  twelfth  an  eruption  appeared,  and  she  died  on  the 
lAventy-second. 


528 

These  symptoms  have  a  very  indefinite  duration,  for  sometimes 
the  patient  dies  in  a  very  few  days ;  in  other  instances'  they  are 
protracted  for  two  or  three  weeks.*  Sometimes  no  hemorrhage 
takes  place  during  the  whole  course  of  the  disease,  but  occasion- 
ally, repeated  hemorrhages  do  occur,  adding  greatly  to  the  debi- 
lity of  the  patient.  In  several  cases,  inflammation  has  come  on, 
and  spread  to  the  intestines.  In  some  of  these,  the  placenta  has 
been  afterwards  expelled,  in  others  extracted ;  but  very  few  have 
recovered.  On  inspecting  the  uterus,  it  has  either  been  found 
black,  as  if  it  had  been  gangrenous,  or  in  a  state  of  high  inflamma- 
tion, or  of  suppuration,  whilst  the  parts  in  the  vicinity  were  in  va- 
rious stages  and  degrees  of  inflammation. 

Now,  when  these  symptoms  have  taken  place,  our  object  ought 
to  be  to  remove  the  cause,  and  support  the  patient  under  the 
disease.  I  am  aware,  that  some  have  attributed  these  symptoms 
not  to  the  placenta,  but  to  concomitant  circumstances,  such  as  in- 
jury done  with  the  hand  in  endeavouring  to  take  it  away.  But 
we  find  that  they  take  place  when  the  whole  of  the  placenta  has 
been  left,  without  any  attempt  having  been  made  to  remove  it. 
They  are  produced  when  any  substance  is  left  to  corrupt  in  utero.f 
They  continue  as  long  as  it  remains,  and  they  usually  cease  when 
it  is  expelled. 

It  may  be  proper  to  examine,  with  the  finger  introduced  into 
the  os  uteri,  whether  any  portion  of  the  placenta  can  be  felt  and 
removed  ;  but  generally  this  cannot  be  freely  done,  for  the  uterus 
itself,  as  well  as  its  mouth,  is  hard  and  contracted,  and  no  violent 
or  painful  attempt  with  the  hand  or  finger  ought  to  be  made.  But 
when  we  can  easily  feel  and  act  upon  a  portion,  we  ought  slowly 
and  gently  to  endeavour  to  bring  it  out ;  and  if  the  whole  of  the 


*  Dr.  Perfect  relates  a  case,  in  which  the  secundines  were  retained  till  the  eighth. 
day,  when  the  patient  died.  Her  stomach  rejected  all  food  and  medicine,  she 
had  weak  quick  pulse,  hiccup,  and  subsultus  tendinum.  Vol.  II.  p.  390. — In  ano- 
ther case,  the  placenta  was  retained  till  the  thirteenth  day,  and  the  woman  died 
on  the  twentieth,  p.  381. 

f  Similar  symptoms  have  been  produced  by  the  head  of  the  child  being  left  in 
utero.    Perfect,  Vol.  II.  p.  80. 


#29 

placenta  have  been  left,  such  attempts  are  still  more  necdssay,  anil 
likely  to  succeed.  The  os  uteri  often  affords  considerable  resis- 
tance to  the  introduction  of  the  hand,  in  cases  where  the  retention 
has  subsisted  for  some  days ;  but  by  very  slow  and  gentle  efforts, 
such  as  are  scarcely  felt  by  the  patient,  it  may  be  dilated,  and  some- 
times it  yields  very  easily,  or  is  not  at  all  contracted.  If,  how- 
ever, it  be  rigid  and  unyielding,  we  must  not  use  violence  ;  but 
this  condition  is  rarely  conjoined  with  retention  of  the  entire  pla- 
centa. 

When  a  portion  of  the  placenta  is  retained,  we  may  derive  ad- 
vantage from  injecting,  frequently,  warm  water,  or  warm  infusion- 
of  camomile  flowers,  or  water  with  a  very  little  muriatic  acid  ad- 
ded to  it.  A  strong  decoction  of  oak  bark,  has  been  proposed,  to' 
tan  the  retained  substance.  These  injections  may  be  made,  by 
"fixing  a  female  catheter  to  an  elastic-gum  bottle  ;  or  a  syringe 
with  a  long  pipe  may  be  employed. 

Sometimes  natural  or  artificial  vomiting  assists  the  expulsion. 

The  patient  should  be  allowed  the  free  use  of  fruit  and  vege- 
table acids,  and  light  mild  diet  should  be  given  in  small  quantity 
•at  a  time.  The  bowels  ought  to  be  kept  open,  and  opiates  should 
occasionally  be  given  to  allay  irritation.  Vomiting  and  nausea 
may  be  checked  or  mitigated  when  urgent,  by  effervescing 
draughts.  Bark,  in  small  doses,  has  been  given,  but  I  cannot 
place  much  confidence  in  it.  When  there  is  a  fulness  about  the 
abdomen,  and  tendency  to  inflammation,  purgatives  are  of  service. 
When  the  nervous  system  is  much  disturbed,  the  camphorated 
mixture  may  be  given  in  its  usual  dose. 


CHAP.  VII. 

Of  Strangury, 

After  severe  labour,  the  neck  of  the  bladder  and  urctlia  ale 
sometimes  extremely  sensible  ;  and  the  whole  of  the  vulva  is  ten- 

68 


530 

cler,  and  of  a  deep  red  colour.  This  is  productive  of  very  dis- 
tressing strangury,  which  is  occasionally  accompanied  with  a  con- 
siderable degree  of  fever.  It  is  long  of  being  removed,  but  yields 
at  last  to  a  course  of  gentle  laxatives,  opiates,  and  fomentations. 
Anodyne  clysters  are  of  service. 


CHAP.  VIII. 

Of  Pneumonia. 

It  is  unnecessary  to  detail  the  symptoms  of  inflammation  of  the 
.lungs  or  pleura.  It  is  sufficient  to  say,  that  this  disease  is  not  un- 
common in  the  puerperal  state  ;  and  if  there  be  such  a  state  of  the 
lungs  during  pregnancy,  as  tends  toward  phthisis,  that  disease  is 
exceedingly  apt  to  be  rapidly  induced  after  delivery. 

Pleurisy  requires,  on  the  first  attack,  copious  blood-letting,  laxa- 
tives, and  blisters,  which  are  never  to  be  omitted.  If  the  early 
stage  have  passed  over,  the  use  of  the  lancet  is  doubtful,  and  it  is 
better  to  trust  to  digitalis  given  freely,  and  the  application  of  blis- 
ters.    Laxatives  are  also  not  to  be  neglected. 


CHAP.  IX. 

Of  Spasmodic  and  Nervous  Diseases. 

Palpitation  is  not  an  uncommon  disease  after  delivery.  It 
usually  attacks  the  patient  suddenly,  and  often  after  a  slight  alarm. 
She  feels  a  violent  beating  in  the  breast,  and  sometimes  has  a  sense 
of  suffocation ;  she  has  also  a  knocking  within  the  headj  with  gid- 
diness and  a  feeling  of  heat  in  the  face. 


531 

The  pulse  is  extremely  rapid  during  the  fit,  and  the  patient  is 
impressed  with  a  belief  that  she  is  going  to  die.  After  the  parox- 
ysm, the  mind  is  left  timid,  and  the  body  languid.  Sometimes  it 
is  succeeded  by  a  profuse  perspiration  ;  and  should  the  fits  be  fre- 
quently repeated,  the  temperature  is  variable  during  the  intervals, 
and  the  stomach  is  filled  with  gas.  This  is  often  a  very  obstinate, 
but  it  is  not  a  dangerous  disease,  unless  it  proceed  from  uterine 
disease,  marked  by  pain  and  swelling  of  the  belly.  It  is  to  be  re- 
lieved by  giving,  during  the  paroxysm,  a  liberal  dose  of  ether  and 
laudanum  ;  and  during  the  intervals,  antispasmodics,  laxatives,  and 
tonics  are  to  be  employed.  As  soon  as  possible,  the  patient  should 
remove  to  the  country. 

Hysteric  fits,  hiccup,  syncope,  and  dyspnoea,  are  to  be  treated 
upon  general  principles,  by  full  doses  of  opium,  and  other  anti- 
spasmodics, and  clearing  out  the  bowels  with  purgatives.  When 
a  patient  is  known  to  be  subject  to  syncope,  it  will  be  proper  to 
give  her,  the  instant  the  child  is  born,  a  draught  containing  spiritus 
.ammonias  aromaticus,  and  laudanum,  and  to  have  the  abdomen 
firmly  supported  by  a  bandage. 

There  is  a  species  of  dyspnoea,  that  depends  upon  exertion  of 
the  muscles  of  respiration  during  labour,  or  distention  of  the  abdo- 
minal muscles.  When  the  abdominal  muscles  are  affected,  the  per- 
son often  feels  the  difficulty  of  breathing,  chiefly  during  expiration. 
It  is  relieved,  by  tightening  a  little  the  compress  round  the  belly, 
and  giving  thirty  drops  of  laudanum.  When  the  diaphragm  is  af- 
fected, the  uneasiness  is  usually  greatest  during  inspiration ;  and 
there  is  often  a  pain  in  the  side,  or  in  the  back,  or  about  the  pit  of 
the  stomach,  which  may  be  very  severe.  It  is  attended,  sometimes, 
with  a  sense  of  stuffing  in  the  breast;  in  other  cases,  with  an  acute 
feeling  of  suffocation,  or  very  sharp  pain  across  the  lower  part  of 
the  thorax,  with  deadly  paleness,  and  the  pulse  is  extremely  rapid. 
A  very  large  dose  of  laudanum,  with  ether  or  volatile  tincture  of 
valerian  removes  the  spasm  ;  if  not,  a  sinapism  must  be  applied. 
These  affections  come  on  within  a  few  hours  after  delivery.  The 
spasm  of  the  diaphragm  is  to  be  distinguished  from  pleurisy,  by- 
its  coming  on  suddenly,  and  being  very  acute;  whereas,  inflam- 
mation comes  on  more  slowly,  and  is  often  preceded  by  a  shiver* 


532 

ing  fit;  there  is  more  cough,  and  the  pulse  at  first  is  not  so  frequent, 
but  is  sharp. 

Dyspnoea  is  also  occasionally  produced  by  the  roller  being  too 
tight. 

Colic  may  occur  within  a  few  days  after  delivery.  It  attacks 
■suddenly,  and  generally  in  the  evening.  It  is  not  preceded  by 
shivering,  but  is  sometimes  accompanied  with  sickness.  The 
pulse  may  at  first  be  either  slow  or  of  the  natural  frequency,  but 
soon  becomes  frequent.  The  pain  is  subject  to  exacerbation  and 
remission,  but  sometimes  does  not  entirely  go  off  for  several 
hours.  The  chief  risk  of  this  disease,  is  the  induction  of  inflam- 
mation, if  the  irritation  be  not  soon  removed.  The  best  remedy 
is,  from  two  drachms  to  half  an  ounce  of  oil  of  turpentine,  with 
«ome  other  laxative,  such  as  half  an  ounce  of  castor  oil,  or  tincture 
of  senna.  I  was  led  to  employ  this  remedy  in  painful  afTectione 
of  the  stomach  and  bowels,  not  dependent  on  inflammation,  from 
witnessing  its  excellent  effects  in  the  hands  of  veterinary  practi- 
tioners, and  from  observing  its  safe  and  purgative  quality  in  the 
human  bowels,  when  given  as  a  cure  for  tenia.  If  the  turpentine 
fail,  a  large  dose  of  laudanum  is  to  be  given  in  a  clyster,  and 
fomentations  are  to  be  used  at  the  same  time.  It  is  generally 
beneficial  to  precede  the  anodyne  by  a  saline  clyster.  If  the  symp- 
toms do  not  go  entirely  off,  the  saline  julap  with  laudanum  is  of 
service.  If  there  be  much  flatulence,  tincture  of  asafcetida  and 
hyoscyamus  are  proper.  Cramp  in  the  stomach  is  very  dangerous, 
when  it  occurs  within  three  weeks  after  delivery.  It  requires  the 
immediate  exhibition  of  turpentine,  and  if  that  fail,  of  at  least  sixty, 
perhaps  a  hundred  drops  of  laudanum,  with  a  drachm  of  sulphuric 
ether,  or  two  drachms  ofspiritus  ammonia;  aromaticus;  a  sinapism 
is  also  to  be  applied  to  the  region  of  the  stomach. 

Pain  in  the  region  of  the  kidney  sometimes  proves  very  trou- 
blesome for  two  or  three  days  after  delivery.  It  comes  in 
paroxysms,  which  are  relieved  by  sinapisms,  fomentations,  clys- 
'ters,  purges,  and  opiate.?. 


5$3 

CHAP.  X. 

Of  Ephemeral  Fever  or  Weed. 

The  increased  irritability  of  the  system,  as  well  as  the  delicacy 
of  particular  organs  after  delivery,  render  women  at  that  time  pe- 
culiarly liable  to  febrile  affections.  Some  of  these  seem  to  arise 
from  the  general  irritability  of  the  whole  nervous  system,  others 
from  local  affection  of  the  breasts,  the  bowels,  or  the  uterus.  The 
first  of  these  symptomatic  fevers,  is  generally  pretty  easily  recog- 
nised by  the  sensibility  of  the  breasts;  the  others,  particularly  that 
connected  with  the  state  of  the  womb,  are  often  more  ambiguous,, 
the  local  symptoms  being  in  many  cases  insidious. 

The  ephemera,  or  weed,  as  it  has  been  called,  is  a  fever  usually 
of  short  duration  ;  the  paroxysm  being  completed  generally  within 
twenty-four,  and  always  within  forty-eight  hours  ;  for  if  it  continue 
longer,  it  becomes  a  fever  of  a  different  description.  It  proceeds 
from  great  susceptibility  of  the  nervous  system,  by  which  slight 
exposure  to  cold,  mental  agitation,  or  similar  causes,  excite  a  uni- 
versal disorder  of  the  frame.  It  consists  of  a  cold,  a  hot,  and  a 
.sweating  stage ;  but  if  care  be  not  taken,  the  paroxysm  is  apt  to 
return ;  and  we  have  either  a  distinct  intermitting  fever  established, 
or  sometimes,  from  the  co-operation  of  additional  causes,  a  con- 
tinued and  very  troublesome  fever  is  produced. 

This  disease,  which  in  its  simplest  form  is  very  much  of  a  ner- 
vous nature,  generally  makes  its  attack  within  a  week  after  de- 
livery. It  may  be  excited  by  exposure  to  cold,  irregularities  of 
diet,  fatigue,  exhaustion,  passions  of  the  mind,  or  want  of  rest.  It 
is  sometimes  directly  ushered  in  with  a  fit  of  palpitation,  or  is  pre- 
ceded by  a  frightful  dream,  from  which  the  patient  awakes  in  a 
shivering  fit,  with  a  rapid  pulse ;  or  the  chill  comes  on,  accom- 
panied with  pain  in  the  back  and  head,  after  some  slight  alarm,  or 
injudicious  exposure  to  cold.  When  the  cold  stage  has  continued 
for  some  time,  the  hot  one  commences,  and  this  ends  in  a  profuse 
perspiration,  which  either  carries  off  the  fever  completely,  or  pro- 
cures a  great  remission  of  the  symptoms.     The  head  is  usually 


534 

pained,  often  intensely,  especially  over  the  eyes,  in  the  two  first 
stages.  The  pulse  is  extremely  rapid,  until  the  third  stage  has 
continued  for  some  time ;  it  is  also  subject  to  very  great  irregula- 
rities, and  is  very  changeable  in  its  degree  of  frequency.  The 
thirst  is  considerable,  the  stomach  generally  filled  with  flatus,  and 
the  belly  bound.  The  mind  often  is  weakened,  and  the  patient  is 
much  afraid  of  dying.  In  some  instances,  she  is  slightly  delirious ; 
in  others,  she  has  shifting  pains  in  the  abdomen.  If  the  paroxysm 
be  repeated,  the  secretion  of  milk  is  diminished. 

The  paroxysm  continues  for  some  hours,  and  then  may  com- 
pletely go  off,  not  to  return  again.  But  in  other  cases,  it  recurs 
frequently,  being  always  preceded  by  a  cold  fit,  and  often  with  a 
pain  in  the  back ;  and  sometimes  the  fit  begins  regularly  one  or 
two  hours  sooner  every  succeeding  day.  It  is  more  favourable 
when  the  fit  postpones.  When  this  disease  is  not  combined  with 
any  local  injury,  it  is  less  dangerous  than  most  fevers  occurring  in 
child-bed ;  but  if  it  recur  very  frequently,  and  be  attended  with 
much  debility,  the  danger  increases  in  proportion  to  the  continu- 
ance of  the  disease.  Local  derangement  may  take  place  very 
suddenly  in  the  course  of  this  ailment ;  the  breasts  are  peculiarly 
liable  to  become  inflamed ;  but  more  frequently,  these  local  affec- 
tions are  rather  causes  than  effects  of  the  febrile  state ;  and  in  all. 
cases,  where  the  paroxysms  are  repeated,  it  is  necessary  to  ex- 
amine carefully  into  the  state  of  every  organ,  especially  that  of  the 
breasts.  A  fatal  termination  is  usually  preceded  by  a  coma,  or 
vomiting  of  dark-coloured  matter. 

Delicate  women,  and  those  who  have  suffered  much  in  parturi- 
tion, are  chiefly  affected  with  this  disease,  but  all  are  more  or  less 
liable  to  it,  especially  if  the  bowels  be  neglected. 

It  is  distinguished  from  symptomatic  fever  arising  from  local  in- 
flammation, by  the  absence  of  the  particular  pain,  and  other  spe- 
cific symptoms,  which  attend  these  fevers,  whilst  in  them  the  pulse 
is  usually  at  first  not  so  rapid  as  in  the  ephemeral  fever. 

In  the  cold  stage,  we  give  small  quantities  of  warm  fluid,  and 
apply  a  bladder  filled  with  warm  water  to  the  stomach,  or  a  warm 
flannel  to  the  back,  on  the  commencement  of  the  chilliness;  or,  if 
the  patient  be  sick,  and  have  a  foul  tongue,  a  gentle  emetic  of 


535 

ipecacuanha  will  be  useful.  If  this  be  not  required,  we  give  a  smart 
dose  of  calomel  and  jalap,  or  some  other  laxative  amongst  the  first 
acts  of  our  practice.  Having  hastened  on  the  hot  stage,  we  lessen 
very  cautiously  the  number  of  the  bed-clothes,  and  give  saline  julap 
with  diluents,  to  bring  on  the  sweating  stage.  When  this  is  done, 
we  are  careful  not  to  encourage  perspiration  too  much,  which  in- 
creases the  weakness,  or  brings  out  a  miliary  eruption,  and  renders 
the  disease  more  obstinate.  On  the  other  hand,  if  the  perspiration 
be  too  soon  checked,  the  fever  continues,  or  recurs  more  severely; 
a  gentle  sweat  may  be  kept  up  for  five  or  six  hours  by  tepid  fluids. 
Then  we  refrain  from  them;  and  when  the  process  is  over,  the  par 
tient  is  to  be  cautiously  shifted,  the  clothes  being  previously  warm- 
ed. After  the  fit,  if  the  patient  is  exhausted,  a  little  wine  may  be 
given.  In  the  whole  paroxysm,  we  must  watch  against  the  sudden 
application  of  cold,  which,  in  the  two  last  stages,  renews  the  shi- 
vering. When  the  fits  recur,  we  may  sometimes  check  them,  by 
giving  an  opiate  with  ether,  just  before  the  expected  accession, 
and  applying  heat  to  the  back  and  stomach,  the  moment  the  chilli- 
ness is  felt.  It  is  of  great  consequence  to  keep  the  bowels  open, 
by  such  medicine  as  agrees  best  with  the  patient,  for  the  parox- 
ysms often  are  repeated,  from  intestinal  irritation  alone.  Tonic 
medicines,  such  as  infusion  of  bark,  sulphuric  acid,  or  solution  of 
arsenic,  are  useful ;  and  in  some  cases  valerian  may  be  joined  to 
these  with  advantage.  Sleep  is  to  be  procured  by  opiates.  During 
the  whole  time,  the  strength  must  be  supported  by  suitable  dietj 
and  as  soon  as  possible,  the  patient  should  be  carried  to  the  coun- 
try. If  the  fits  return  often,  it  is  generally  necessary  to  give  up 
nursing. 

If  derangement  of  any  organ  should  take  place  during  the  re* 
currence  of  this  disease,  it  must  be  treated  on  general  principles ; 
and  it  is  to  be  recollected  that  the  nature  of  the  complaint  is  now 
changed,  and  the  organ  which  is  disordered  claims  our  chief  atten- 
tion. Very  frequently  the  breasts  suffer,  or  the  womb  itself  may 
be  attacked.  But  we  must  be  careful  to  distinguish  such  a  modi- 
fication of  weed,  from  a  symptomatic  fever,  beginning  like  weed, 
but  altogether  arising  from  the  state  of  the  womb,  or  other  organs. 
The  distinction  ir»  important,  that  no  time  be  lost  in  combating  the. 


536 

disease  ;  which  in  the  one  case  does  not  at  first  exist,  in  the  other, 
is  present  ah  origine.  When  the  local  affection  is  acute,  die  diag- 
nosis is  easy ;  but  I  wish  it  to  be  impressed  on  the  mind  of  my 
reader,  that  it  may  also  be  mild,  and  require  attentive  inquiry  to  as- 
certain it  satisfactorily. 


CHAP.  XL 

Of  the  Milk  Fever. 

The  secretion  of  the  milk  is  usually  ushered  in  with  a  slight  de- 
cree of  fever,  or,  at  least,  a  frequency  of  the  pulse.  But  sometimes 
it  is  attended  with  a  smart  febrile  fit,  preceded  by  shivering,  and 
going  off  with  a  perspiration.  This  attack,  if  properly  managed, 
seldom  continues  for  twenty-four  hours;  and  during  this  time,  the 
breasts  are  full,  hard,  and  painful,  which  distinguishes  this  from 
more  dangerous  fevers.  Sometimes,  during  the  hot  fit,  there  is  a 
slight  delirium.  A  smart  purge  generally  cures  this  disease,  and  is 
often  used,  in  plethoric  habits,  on  the  third  day  after  delivery,  to 
prevent  it.  Mild  diaphoretics,  during  the  hot  stage,  are  also  proper. 
Applying  the  child  early  to  the  breast  is  a  mean  of  prevention. 


CHAP.  XII. 

Of  Miliary  Fever. 


The  miliary  fever  begins  with  chilliness,  sickness,  languor^ 
sometimes  amounting  to  syncope,  and  frequency  of  pulse,  with 
heat  of  the  skin.  There  is  also  a  sense  of  pricking  or  itching  on 
the  surface ;  and  sometimes  the  extremities  aro  numbed.  The  fe~ 


637 

brile  symptoms  usually  continue  for  some  time  before  the  eruption 
appears,  often  for  four  or  six  days.  Previous  to  the  eruption,  the 
patient  feels  very  much  oppressed,  and  has  a  great  weight  about 
the  chest;  the  spirits  are  low,  and  a  sour-smelled  perspiration 
takes  place  in  a  profuse  degree.  The  eyes  are  occasionally  dull 
and  watery,  or  inflamed,  and  the  patient  has  ringing  in  the  ears. 
The  tongue  is  foul,  and  its  edge  red  as  in  scarlatina.  Aphthae 
sometimes  appear  in  the  throat.  The  lochial  discharge  is  diminished 
or  suppressed.  Before  the  eruption  is  seen,  the  skin  feels  rough 
like  the  cutis  anserina.  Presently  a  number  of  small  red  pustules 
appear  like  millet  seeds,  which  are  felt  with  the  finger  to  be  pro- 
minent. In  a  few  hours,  small  vesicles  form  on  their  tops,  contain- 
ing a  fluid,  first  straw  coloured,  and  then  white  or  yellow.  In  two 
or  three  days  small  scabs  form,  which  fall  off  like  scales.  The  pus- 
tules are  generally  distinct,  but  sometimes  they  form  clusters. 
They  appear  first  about  the  forehead,  neck,  and  breast,  and  then 
spread  to  the  trunk  and  extremities,  but  very  rarely  affect  the  face. 
Different  crops  of  pustules  may  come  out  in  the  same  fever.  Bur- 
serius,  and  others,  divide  the  pustules  into  several  varieties;  but 
most  writers  are  satisfied  with  two,  taken  from  the  general  appear- 
ance, the  red  and  the  white,  and  the  first  is  attended  with  a  mild- 
er disease  than  the  second. 

This  disease  is  peculiarly  apt  to  attack  those  who  are  weakened 
T>y  fatigue,  evacuations,  or  other  causes;  and  hence  we  can  easily 
explain,  why  women  in  child-bed  should  be  subject  to  it. 

Some  have  considered  the  eruption  as  altogether  dependent  on 
the  perspiration.  Others  consider  it  as  in  many  cases  idiopathic; 
and  both,  perhaps,  at  limes  are  right.  We  can  only  consider  the. 
disease  as  idiopathic,  when  the  eruption  mitigates  the  symptoms, 
when  the  fever  goes  off  as  the  pustules  arrive  at  maturity,  and  there 
is  no  other  puerperal  disease  present,  acting  as  an  exciting  cause. 
It  does  not  appear  to  be  contagious,  unless  connected  with  a  fever 
which  is  so  of  itself,  such  as  typhus. 

Miliary  eruption  also  occurs  during  child-bed,  as  a  symptom 
connected  with  puerperal  diseases.  It  often  accompanies  the  milk- 
lever,  or  the  weed,  when  the  perspiration  is  injudiciously  encou- 
raged ;  and  this  is  by  far  the  most  frequent  form,  under  which  the 

G9 


538 

febris  miliafis  appears*.  It  never  alleviates  the  symptoms.  It  may 
also  accompany  fevers  connected  with  a  morbid  state  of  the  peri- 
toneum or  brain,  which  generally  prove  fatal ;  death  being  prece- 
ded by  vomiting  of  dark  coloured  fluid.  Women,  much  reduced, 
have  also  partial  miliary  eruptions,  generally  of  the  white  kind, 
without  fever,  which  require  no  particular  treatment. 

Whether  the  miliary  fever  be  idiopathic,  or  symptomatic,  the 
treatment  is  the  same.  We  endeavour,  at  first,  to  check  or  re- 
move the  fever,  by  means  which  I  have  pointed  out  in  a  former 
chapter. 

When  profuse  perspiration,  with  or  without  eruption,  takes  place, 
we  must  cautiously  abate  it,  by  prudently  lessening  the  quantity 
of  bed-clothes,  or  making  the  bed-room  cooler.  The  rest  of  the 
treatment  consists  cjiiefly  in  removing  irritation  from  the  intes- 
tines by  the  use  of  laxatives,  and  supporting  the  strength  by  light 
nourishing  diet,  whilst  we  use  tonics,  such  as  sulphuric  acid  or 
bark.  These  tend  also  to  abate  the  perspiration,  which  is  scarcely 
ever  to  be  encouraged.  The  linen  should  be  frequently  changed* 
When  the  eruption  suddenly  recedes,  we  have  been  advised  to  re- 
new the  perspiration,  apply  blisters,  and  give  musk  and  cordials^ 
especially  when  convulsions  are  threatened.  This  dangerous  re- 
trocession, however,  1  have  not  met  with,  and  apprehend  that  it, 
^ery  rarely  occurs. 


CHAP.  XIIL 

Of  Intestinal  Fever.. 

Wk  shall  presently  have  an  opportunity  of  observing,  that  the/ 
state  of  the  bowels  frequently  produces  in  children  a  very  trouble- 
some species  of  fever,  which,  though  proceeding  from  a  cause 
which  has  been  some  time  in  existence,  makes  its  appearance 
■tfiddenly.     The  same  holds  true  with  regard  to  women  in  chHd-v" 


539 

bed,  who  cither  from  previous  torpor  or  costivencss  of  the  bowels- 
during  the  end  of  gestation,  or  some  error  in  diet  after  delivery, 
are  seized,  within  eight  or  nine  days,  generally  earlier,  with  fever, 
which  passes  for  weed. 

After  an  attack  of  shivering  and  chilliness,  the  patient  becomes 
sick,  oppressed  at  the  stomach,  and  loathes  food.  The  pulse  is 
frequent,  and  the  skin,  except  at  the  feet,  feels,  from  the  very  first, 
hot  to  the  touch  of  another  person,  though  the  woman  herself  com- 
plains of  being  cold.  Afterwards  she  feels  very  hot,  especially  in 
the  hands  and  feet; — she  has  no  appetite, — is  thirsty, — lias  a  white 
slimy  tongue, — is  sick, — and  occasionally  vomits  phlegm  or  bile 
and  is  troubled  with  flatulence.  The  pulse  is  quick ;  she  does  not 
sleep,  but  rather  slumbers,  and  is  tormented  with  dreams  and 
visions,  and  talks  during  her  slumbers.  Generally  she  complains 
of  throbbing,  often  of  confusion,  but  seldom  of  continued  pain  in 
the  head,  though  for  a  short  time  headach  may  be  severe.  She 
has  no  fixed  pain,  nor  any  tumour  in  the  belly,  but  complain? 
rather  of  stitches  or  griping.  The  bowels  may  either  be  costive 
or  loose  ;  but  in  either  case,  the  stools  are  foetid  and  dark  coloured: 
and,  in  general,  laxatives  operate  both  early  and  powerfully.  The 
lochial  discharge  is  not  necessarily  obstructed,  nor  does  the  secre- 
tion, of  milk  in  many  instances,  suffer  for  several  days.  The  eye 
and  the  countenance  are  nearly  natural.  The  belly  sometimes,  in 
the  course  of  the  disease,  becomes  full  and  soft,  as  if  the  bowels 
were  inflated,  and  this  size  occasionally  continues  during  life. 
These  symptoms  may  be  complicated  with  others,  proceeding 
from  nervous  irritation,  such  as  palpitation,  starting,  Sic,  or  in  the 
course  of  the  disease,  new  ones  arising  from  injury  of  the  function 
of  the  womb,  may*  supervene,  and  are  marked  first  by  pain,  and 
afterwards  by  tumefaction  of  the  lower  part  of  the  belly,  and  pain 
in  making  water,  or  on  passing  the  faeces.  The  duration  of  this 
fever  varies  from  a  few  days  to  a  fortnight.* 

*  Since  the  publication  of  this  work,  the  fever  I  have  called  intestinal,  has 
been  described  by  Dr.  Granville,  in  his  Report,  p.  160.  He  notices  that  it  is 
sometimes,  when  there  is  much  inflation  of  the  bowels,  mistaken  for  puerperal 
fever;  but  the  tumefaction  in  the  intestinal  fever  precedes  pain  in  the  bowels, 
and  the  symptoms  are  decidedly  relieved  by  purgatives. 


540 

On  the  first  appearance  of  this  fever,  a  gentle  emetic  of  ipeca- 
cuanha should  be  administered ;  and  afterwards,  when  the  opera- 
tion is  over,  we  determine  to  the  surface,  by  giving  the  saline  julap 
with  tepid  drink.  Then,  in  a  few  hours,  we  administer  a  dose  of 
rhubarb  and  magnesia  to  remove  offensive  matter  from  the  bow- 
els ;  or,  if  necessary,  we  give  a  suitable  dose  of  castor  oil,  or  calo- 
mel. After  this,  if  there  be  considerable  griping,  or  a  tendency 
to  much  purging,  we  give  an  opiate-clyster,  and  repeat  this  every 
night  till  the  bowels  are  less  irritable,  taking  care,  if  they  become 
costive,  or  the  stools  foetid,  to  interpose,  occasionally,  gentle  laxa- 
tives. The  great  principle  indeed  on  which  we  proceed,  is  the 
early  and  prompt  evacuation  of  the  offensive  matter,  whether 
bilious  or  feculent,  from  the  bowels,  and  the  prevention  of  re-ac- 
cumulation, and  this  must  be  done  by  such  doses  as  are  required. 
The  diet  must  be  very  light,  such  as  beef-tea,  calves  feet  jelly,  ar- 
row root,  &c,  and  if  there  be  no  diarrhoea,  ripe  fruit  may  be  given. 
Ginger  wine  and  water  forms  an  excellent  drink,  and  in  a  few 
days,  such  a  quantity  of  Madeira  wine  may  be  given,  as  is  found 
to  impart  a  comfortable  feeling,  without  inducing  heat  or  restless- 
ness. When  the  tongue  becomes  clean,  small  doses  of  colomba, 
or  other  bitters,  will  be  useful.  If  there  be  much  nervous  irrita- 
tion or  palpitation,  or  tendency  to  delirium,  the  camphorated  julap 
is  proper. 

More  recently  still,  Br.  M.  Hall  appears  to  have  described  this  lever  under  the 
name  of  "  a  serious  puerperal  affection,"  and  enumerates  the  various  complica- 
tions which  may  take  place,  but  which  do  not  seem  essential  to  the  disorder, 
such  as,  vertigo,  palpitation,  feeling  of  sinking,  &c,  and  divides  the  disease 
itself  into  two  varieties,  that  which  takes  place  acutely,  and  that  which  comes 
on  more  slowly ;  the  former  being  preceded  by  more  distinct  shivering,  and 
attended  with  more  severe  affections  of  the  brain  or  abdominal  viscera,  than  the 
latter. 


54  i     * 

CHAP.  XIV. 

Of  Inflammation  of  the  Uterus. 

Inflammation  of  the  womb  may  appear  under  two  forms,  the 
slight  and  the  extensive.     This  is  a  distinction  which  those  who 
are  not  much  conversant  in  practice,  may  not  be  disposed  to  ad- 
mit ;  but  it  will,  nevertheless,  be  useful  to  describe  them  separate- 
ly.    The  first  begins  within  the  ninth  day,  very  like  the  epheme- 
ral fever,  and  is  considered  by  the  nurse  as  a  weed.     The  patient 
shivers,  feels  cold,  is  sick,  and  perhaps  vomits.     The  pulse  is  fre- 
quent, but  not  hard  nor  sharp,  the  skin  becomes  warm,  and  be- 
tween the  cold  and  the  establishment  of  the  hot  stage,  the  patient 
complains  of  a  dull  pain  in  the  lower  part  of  the  belly.     It  is  not 
constant,  and  is  apt  to  pass  for  after-pains.     The  lochial  discharge 
continues,  and  the  secretion  of  milk  is  not  checked.     The  pain,  at 
first,  and  usually  during  the  whole  course  of  the  disease,  is  slight, 
it  is  generally  felt  near  the  pubis,  but  it  may  also  extend  a  little  to 
one  side,  or  toward  the  groin.     Sometimes  there  is  pain  in  the 
back,  but  frequently  there  is  none,  unless  when  the  patient  sits  up. 
The  pain  in  the  belly  very  soon  is  not  perceived  when  she  lies 
still,  but  is  felt  when  she  turns,  or  when  pretty  considerable  pres- 
sure is  made  with  the  hand,  or  occasionally  one  or  two  sharp  pains 
dart  through  the  uterine  region.     There  is  no  hardness  to  be  felt, 
and  the  belly  is  not  tender,  but  becomes  a  little  full ;  the  lochial 
discharge  gradually  diminishes,  but  does  not  of  necessity  stop,  and 
the   milk  sometimes  continues  plentiful.     There  is  considerable 
thirst,  no  appetite,  and  the  sleep  is  disturbed.     The  pulse,  which 
at  first  is  very  frequent,  falls  in  a  day  or  two  to  100,  or  varies  from 
90  to  108.     The  head  is  confused  rather  than  painful,  slight  wan- 
dering pains  may  be  felt  in  the  belly  or  sides.     The  bowels  are 
generally  affected,  being  at  first  rather  bound,  afterwards  loose  or 
irregular,  and  the  faeces  dark,  slimy,  or  foetid.     Sometimes  there 
is  a  degree  of  strangury.     In  the  course  of  a  fortnight,  the  pulse 
becomes  slower,  the  appetite  gradually  returns,  and  these  circum- 
stance- are  preceded  or  accompanied  with  p.  slight  discharge  of 


542 

blood  from  the  womb,  or  of  purulent  matter  by  the  rectum,  or  from 
the  vagina.  Sometimes  the  disease  is  much  shorter  in  its  course, 
being  little  more  protracted  than  an  ephemera,  the  symptoms  yield- 
ing completely  to  the  treatment ;  or  they  may  be  removed  in  so 
far  as  that  all  fever  and  pain  go  off;  but  when  the  patient  comes 
to  rise,  she  feels  a  pressure  like  prolapsus  uteri,  which  continues 
for  many  days  or  even  weeks,  so  that  she  cannot  stand,  but  has  an 
instinctive  desire  to  run  to  a  seat.  It  is  not  easy  to  distinguish 
this  state  from  prolapsus,  except  by  examination.  The  uterus  is 
felt  in  its  proper  altitude,  but  often  the  os  uteri  is  turned  a  little 
to  one  side,  and  the  vagina  is  not  lax,  but  may  be  rather  rigid  : 
pessaries  give  little  or  no  relief.  The  complaint  continues  obsti- 
nate, preventing  the  patient  from  walking,  though  she  is  in  tolera- 
ble health,  until  a  little  purulent  matter,  or  still  more  frequently,  a 
little  blood,  like  the  menses,  be  discharged,  and  then  she  is  almost 
instantly  cured. 

The  treatment  of  this  species  of  uterine  inflammation  consists 
in  exciting  early  a  free  and  pretty  copious  perspiration,  fomenting 
the  belly,  and  opening  the  bowels  with  a  smart  purge.  If  the 
pains  be  more  permanent,  blisters  may  be  necessary,  and  blood- 
jetting,  early  employed,  is  useful,  but  most  cases  of  this  partial  na- 
ture recover  without  the  use  of  the  lancet,  merely  by  cuticular  and 
intestinal  evacuation. 

The  more  serious  and  extensive  inflammation  of  the  uterus  may 
be  excited  in  consequence  of  rude  management,  or  other  causes. 
The  disease  usually  begins  between  the  second  and  fifth  day  after 
delivery,  but  it  may  take  place  at  a  later  period.  It  is  pointed  out 
by  a  pain  in  the  lower  part  of  the  belly,  which  gradually  increases 
in  violence,  and  continues  without  intermission,  though  it  is  subject 
to  occasional  aggravations.  These  aggravations,  at  first,  seem  to 
proceed  from  contractions  or  spasms  of  the  inflamed  fibres.  The 
uterine  region  is  very  painful  when  it  is  pressed,  and  it  is  a  little 
swelled.  There  is,  however,  no  general  swelling  of  the  abdomen 
with  tension,  unless  the  peritoneum  have  become  affected.  But 
the  parietes  are  rather  slack,  and  we  can  feel  distinctly  the  uterus 
Through  them,  to  be  harder  than  usual,  and  it  is  very  sensible. 
There  is  also  pain  felt  in  the  back,  which  shoots  to  the  groins,  ac- 


.543 

xjompanied  with  sensation  of  weight ;  and  there  is  usually  a  rti/H- 
«ulty  in  voiding  the  urine,  or  a  complete  suppression,  or  distressing 
-degree  of  strangury.  The  situation  of  the  pain  will  vary  according 
to  the  part  of  the  uterus  first  and  principally  affected.  The  inter- 
nal parts  also  become  frequently  of  a  deep  red  colour,  and  the  va- 
gina and  uterus  have  their  temperature  increased.  The  lochial  dis- 
charge is  very  early  suppressed,  and  the  secretion  of  milk  dimin- 
ished or  destroyed.  Nearly  about  the  same  time  that  the  local 
symptoms  appear,  the  system  becomes  affected.  The  patient  has 
headach,  often  is  sick,  vomits  bilious  fluid,  and  generally  feels 
chilly.  The  pulse  very  early  becomes  frequent,  and  somewhat 
hard,  and  the  skin  is  felt  to  be  hot.  The  tongue  is  white  and  dry, 
the  urine  high  coloured  and  turbid,  and  if  the  bladder  be  affected, 
it  may  be  suppressed.  The  vomiting  in  some  cases  continues,  and 
the  bowels  are  at  first  bound,  but  afterwards  the  stools  are  passed 
more  frequently.  If  the  peritoneum  come  to  partake  exten- 
sively of  the  disease,  then  we  have  early  swelling,  and  tenderness 
of  the  abdomen,  and  the  danger  is  greatly  increased.  Sometimes 
the  internal  or  mucous  membrane  is  chiefly  affected,  and,  suc- 
ceeding to  pain,  fever,  and  suppression  of  the  lochia,  we  have  a 
puriform  discharge. 

If  the  inflammation  do  not  extend  along  the  peritoneum,  this 
disease  is  more  easily  cured  than  other  visceral  inflammations  in 
the  puerperal  state.  It  may  terminate  favourably  by  a  free  perspi- 
ration, a  diarrhoea,  or  a  uterine  hemorrhage;  which  last  is  the  most 
frequent  and  complete  crisis.  If  the  pain  abate,  the  pulse  coins' 
down,  and  the  lochia  and  secretion  of  milk  return,  we  consider  the 
patient  as  having  the  prospect  of  a  speedy  cure.  But  in  many- 
other  cases  the  disease  is  more  obstinate,  the  fever  continues,  the 
pulse  becomes  more  frequent,  but  is  full  for  a  day  or  two,  after 
which  it  becomes  small,  the  tongue  is  redder,,  but  dry,  the  pain 
does  not  abate,  and  in  some  days,  shiverings  take  place,  and  the 
pain  becomes  of  the  throbbing  kind.  The  face  is  pale,  unless  when 
the  cheeks  have  a  hectic  flush ;  the  urine,  which  was  formerly  high 
coloured,  now  deposits  a  pink-coloured  sediment,  in  great  abun- 
dance. The  nights  are  spent  without  sleep,  and  the  patient  is  wet 
with  perspiration,    After  some  time,  matter  is  discharged  from  the 


§44 

Vagina,  or  by  tiie  bladder  or  rectum,  but  oftenest  from  the  rectum. 
The  hectic  symptoms  continue  for  many  weeks,  and  may  at  last 
prove  fatal.  Sometimes  the  disease  early  proves  fatal,  the  pulse  in- 
creasing in  frequency,  the  tongue  becoming  very  red,  and  the 
strength  sinking ;  but,  even  in  this  case,  it  will  generally  be  found 
that  suppuration  has  taken  place.  Pus  is  contained  often  in  the 
ovaria  and  tubes,  and  sinuses  of  the  uterus.  Mortification  is  an  ex- 
tremely rare  termination.  This  is  a  fact  of  which  my  dissections 
convince  me,  and  it  is  farther  confirmed  by  the  opinion  of  Dr. 
Clarke.  Little  or  no  serous  effusion  takes  place  into  the  abdomen. 
In  some  cases  the  veins  participate  very  extensively  in  the  disease, 
and  become  inflamed  to  a  great  distance.  Thus  inflammation  may 
spread  toward  the  heart  or  liver,  or  down  along  the  veins  of  one  or 
both  thighs.  This  is  attended  with  great  and  debilitating  fever, 
and  much  pain  in  the  course  of  the  affected  veins,  which,  after 
death,  are  found  inflamed,  thickened,  or  filled  with  pus.  The 
treatment  of  this  complication  must  be  conducted  on  the  antiphlo- 
gistic plan,  and  a  knowledge  of  the  nature  of  the  disease  will  call 
for  early  attention  to  local  pain  attended  with  fever. 

Inflammation  of  the  uterus  may  arise  without  any  very  perceptible 
predisposing  or  exciting  cause,  but  frequently  it  is  distinctly  attri- 
butable to  previous  exertion  during  tedious  labour,  or  to  rash  ma- 
nual interference,  or  hurried  extraction  of  the  placenta,  or  exposure 
to  cold.  It,  as  well  as  peritoneal  inflammation,  is  also  peculiarly 
apt  to  affect  those  who  have  suffered  from  uterine  hemorrhage. 

This  disease  calls  for  the  early  and  free  use  of  the  lancet,  which 
is  the  principal  remedy ;  and  the  number  of  times  that  we  repeat 
the  evacuation  must  depend  on  the  constitution  of  the  patient,  the 
effects  produced,  and  the  period  of  the  disease.*  If  three  or  four 
days  have  passed  over,  the  pulse  may  be  full  and  frequent ;  but 
this  is  an  indication  that  suppuration  is  going  on,  which  will  be  as- 
certained by  throbbing  pain,  &,c.  In  this  case  the  lancet  is  hurtful. 
Mild  laxatives  are  also  highly  proper.     Fomentations,  or  a  cloth 

*  The  French  writers  erroneously  do  not  consider  the  lancet  as  requisite,  tin- 
less  the  symptoms  be  very  acute,  but  trust  rather  to  leeches  applied  to  the  vul 
Ciavdicn,  Tom.  III.  p.  147. 


545 

soaked  in  oil  of  turpentine,  are  useful.  Diaphoretics  ought  to  Lie 
administered,  such  as  the  saline  julap,  with  the  addition  of  antimo- 
nial  wine  and  laudanum.  This  is  the  best  internal  remedy  I  think 
we  can  employ.  Emollient  clysters,  or  sometimes  anodyne  clys- 
ters, give  relief.  In  the  suppurative  stage,  we  must  keep  the  bowels 
open,  give  light  nourishment,  apply  fomentations,  and  allay  pain 
with  anodynes.  When  the  matter  is  discharged,  a  removal  to  the 
country  will  be  useful,  and  tonic  medicines  should  be  given. 

Sometimes  the  round  ligament  suffers  chiefly,  and  the  patient 
complains  of  pain  and  tenderness  at  the  groin,  increased  by  pres- 
sure. The  lower  part  of  the  belly  is,  after  a  little,  swelled  and  un- 
easy. Fever  attends  this  disease,  and  sometimes  the  stomach  be- 
comes irritable.  It  is  often  caused  by  hasty  extraction  of  the  pla- 
centa. It  requires  the  early  use  of  laxatives ;  and  if  the  symptoms 
are  violent,  it  is  proper  to  take  blood  from  the  arm,  and  apply 
leeches  to  the  groin,  which  should  seldom  be  omitted.  Afterwards 
we  employ  fomentations  and  blisters.  If  neglected,  the  disease 
may  end  in  suppuration,  or  in  a  painful  swelling  at  the  ring  of  the 
oblique  muscle,  which  lasts  a  long  time.  This  is  sometimes  re- 
moved by  issues.  Anodynes  should  be  given  to  allay  irritation, 
and  the  strength  must  be  supported  under  the  fever,  which  resem- 
bles hectic. 


CHAP.  XV. 

Of  Peritoneal  Inflammation. 

The  peritoneal  lining  of  the  abdomen,  or  the  covering  of  the 
intestines,  may  be  inflamed  alone  ;  or  this  disease  may  be  com- 
bined with  inflammation  of  the  uterus. 

Peritoneal  inflammation  may  be  caused  by  violence  during  de- 
livery, or  the  application  of  cold,  or  the  injudicious  use  of  stimu- 
lants. Those  who  have  suffered  from  uterine  hemorrhage  aftev 
delivery,  are  most  liable  to  this  disease,  as  well  as  to  inflammation 

70 


546 

of  the  uterus.  It  may  not  come  on  for  three  weeks  after  delivery, 
but  it  usually  commences  on  the  second  day,  and  earlier  than  in- 
flammation of  the  womb ;  and  it  may  often  be  observed,  that  the 
pulse  continues  frequent  from  the  time  of  delivery.  It  is  preceded 
or  attended  by  a  shivering  and  sickness,  or  vomiting,  and  is  mark- 
ed by  pain  in  the  belly,  which  sometimes  is  very  universal ;  though, 
in  other  cases,  it  is  at  first  confined  to  one  spot.  The  abdomen 
very  soon  becomes  swelled  and  tense,  and  the  tension  rapidly  in- 
creases. The  pulse  is  frequent,  small,  and  sharp,  the  skin  hot,  the 
tongue  either  clean,  or  white  and  dry,  the  patient  thirsty ;  she  vo- 
mits frequently,  and  the  milk  and  lochia  are  obstructed.  These 
symptoms  often  come  on  very  acutely,  but  it  ought  to  be  deeply 
impressed  on  the  mind  of  the  student,  that  they  may  also  approach 
insidiously.  Wandering  pain  is  felt  in  the  belly,  neither  acute  nor 
altogether  constant.  It  passes  for  after-pains,  but  it  is  attended 
with  frequency  of  pulse,  and  some  fulness  of  the  belly,  and  a  little 
sickness.  But  whether  the  early  symptoms  come  on  rapidly  or 
slowly,  they  soon  increase,  the  belly  becomes  as  large  as  before 
delivery,  and  is  often  so  tender,  that  the  weight  of  the  bed-clothes 
can  scarcely  be  endured ;  the  patient  also  feels  much  pain  when 
she  turns.  The  respiration  becomes  difficult,  and  sometimes  a 
cough  comes  on,  which  aggravates  the  distress ;  or  it  appears  from 
the  first,  attended  with  pain  in  the  side  as  a  prominent  symptom. 
Sometimes  the  patient  has  a  great  inclination  to  belch,  which  al- 
ways gives  pain.  The  bowels  are  either  costive,  or  the  patient 
purges  bilious  or  dark  coloured  fteces.  These  symptoms  are  more 
or  less  acute,  according  to  the  extent  to  which  the  peritoneum  is 
affected.  They  are,  at  first,  milder,  and  more  protracted,  in  those 
cases  where  the  inflammation  begins  in  the  uterus;  and,  in  such, 
the  pain  is  often  not  very  great,  nor  very  extensive,  for  some  time. 
If  the  disease  is  to  prove  fatal,  the  swelling  and  tension  of  the  belly 
increase,  so  that  the  abdomen  becomes  round  and  prominent,  the 
vomiting  continues,  the  pulse  becomes  very  frequent  and  irregular, 
the  fauces  are  aphthous,  death  is  marked  in  the  countenance,  the 
extremities  cold,  and  the  pain  usually  ceases  rather  suddenly. 
The  patient  has  unreireshing  slumber,  and  sometimes  has  delirium 
mite,  but  she  may  also  remain  sensible  till  the  last.     The  disease 


547 

usually  proves  fatal  within  five  clays,  but  may  be  protracted  for 
eight  or  ten  days,  or  even  longer.  If  the  patient  is  to  recover,  the 
swelling  does  not  proceed  to  a  great  degree ;  the  pain  gradually 
abates,  the  vomiting  ceases,  the  pulse  becomes  fuller  and  slower, 
the  breathing  easier,  so  that  the  patient  can  lie  better  down  in  bed, 
and  she  can  turn  more  easily.  Sometimes  this  disease  ends  in  sup- 
puration, and  the  abscess  points  and  bursts  externally.  Dr.  Gor- 
don, in  his  treatise  on  puerperal  fever,  relates  three  cases  of  this 
kind.  In  one  of  these,  the  matter  was  discharged  from  the  umbi- 
licus, a  month  after  the  attack  ;  in  another,  six  weeks  after  deli- 
very ;  and  in  the  third,  after  two  months  it  came  from  the  urethra. 
Similar  cases  have  come  under  my  own  observation. 

Upon  dissection,  the  peritoneum  is  found  in  a  state  of  high  in- 
flammation, but  it  is  rare  to  find  it  mortified.  A  considerable  ef- 
fusion of  serous  fluid,  mixed  with  curdy  substance,  is  found  in  the 
belly. 

The  patient  is  only  to  be  saved  by  vigorous  means,  and  great  at- 
tention. If  the  pulse  continue  above  a  hundred  in  the  minute,  for 
twenty-four  hours  after  delivery,  there  is  reason  to  apprehend  that 
some  serious  mischief  is  about  to  happen  ;  and  therefore,  unless 
the  frequency  depend  decidedly  on  debility,  produced  by  great 
hemorrhage,  &c.  we  ought  to  open  the  bowels  freely,  and  give  a 
diaphoretic.  We  must  carefully  examine  the  belly,  and  if  it  be  full, 
or  painful  on  pressure,  or  if  the  patient  be  inclined  to  vomit,  we 
ought  instantly  to  open  a  vein,  and  use  purgatives.  One  copious 
bleeding,  on  the  very  invasion  of  the  disease,  is  more  useful  than 
ten  afterwards  ;  and  the  delay  of  two  hours  may  be  the  loss  of  the 
patient.  I  know  that  many  are  unwilling  to  bleed  women  in 
the  puerperal  state,  and  the  condition  of  the  pulse  may  seem  to 
young  practitioners  to  forbid  it.  But  in  cases  of  peritoneal  inflam- 
mation, not  connected  with  contagious  fever,  I  must  strongly  urge 
the  necessity  of  blood-letting,  at  a  very  early  period ;  and  the  eva- 
cuation is  to  be  repeated  or  not,  according  to  its  effects,  and  the 
constitution  of  the  patient.  If  she  have  borne  it  ill,  and  not  been 
relieved,  when  it  was  used  first,  I  apprehend  that  the  case  has  not 
been  simple  peritoneal  inflammation,  but  puerperal  fever.  If  she 
bear  it  well,  and  the  pulse  become  slower  and  fuller,  and  the  pain 


548 

abate,  we  are  encouraged  to,  repeat  it.  I  wish  to  impress  on  the 
mind  of  the  student,  in  the  most  earnest  manner,  the  fatal  conse- 
quence of  neglecting  blood-letting  in  this  disease.  How  many  wo- 
men fall  a  sacrifice  to  the  timidity  or  inattention  of  their  attendant! 
The  lancet  is  the  anchor  of  hope :  it  may  indeed  be  pushed  too  far; 
it  may  be  used  by  young  practitioners  in  cases  of  spasm,  mistaken 
for  peritonitis  ;  but  the  error  is  safer  than  the  contrary  extreme,  for 
of  two  evils  debility  is  more  easily  removed  than  inflammation. 
When  I  say  this,  however,  I  do  not  mean  to  urge  the  senseless  and 
extravagant  use  of  the  lancet.  A  prudent  practitioner  will  bleed 
early  and  freely,  so  long  as  he  is  thereby  abating  inflammation  ; 
but  he  will  stop  in  time,  and  observe  whether  he  be  really  gaining 
advantage  by  evacuation,  or,  on  the  contrary,  sinking  the  patient, 
and  destroying  that  vigour  which  is  necessary  for  an  effort  to  reco- 
ver. He  will  never  bleed  late  in  the  disease,  unless  it  be  to  sub- 
due an  exacerbation,  and  unless  the  beneficial  result  of  his  practice 
confirm  its  propriety.  Whilst  some  have  been  dilatory  and  too 
timid,  others,  I  fear,  have  sunk  their  patients  as  effectually  by  in- 
ordinate evacuation,  as  if  they  had  left  the  inflammation  quite  un- 
controlled. After  the  lancet  has  been  freely  used,  if  pain  continue, 
leeches,  or  the  scarificator,  may  be  applied  to  the  most  painful 
part.  The  bowels  are  at  the  very  first  to  be  opened  freely  with 
calomel,  or  some  other  purgative,  which  we  require  to  give  in  a 
large  dose,  particularly  calomel,  for  ordinary  doses  do  no  good. 
Dr.  Armstrong  gives  half  a  dram  of  calomel,  and  afterwards  a  pur- 
gative draught  of  senna  and  salts  to  work  it  off,  and  I  think  the 
practice  safe.  In  an  advanced  stage  of  the  disease,  after  effu- 
sion has  taken  place,  we  must  employ  purges  alone,  rather  than 
blood-letting.  Sinapisms  and  blisters  are  also  proper.  Digitalis 
has  been  given,  either  to  abate  inflammation,  or  promote  absorp- 
tion after  effusion  has  taken  place  ;  but  I  have  not  found  it  useful. 
After  effusion  has  taken  place,  and  debility  is  produced,  cordials, 
of  which  wine  is  the  best,  should  be  given,  and  anodyne  clysters  are 
to  be  administered.  There  are  one  or  two  cases  recorded,  where 
the  fluid  had  been  either  spontaneously  discharged  by  an  opening 
taking  place  in  the  intestine,  or  artificially  by  paracentesis,  and 
with  a  good  effect. 


549 

Chronic,  or  slow  inflammation  of  the  peritoneum,  is  not  very 
unfrequcnt,  and  may  last  for  some  weeks.  It  is  attended  with  con- 
stant pain  in  some  part  of  the  abdomen,  but  it  is  not  unbearable; 
the  belly  is  tender,  the  pulse  frequent,  the  thirst  urgent,  and  often 
the  mind  is  affected  as  in  hysteria  ;  or  a  train  of  hysterical  symp- 
toms supervenes,  which  may  lead  off  the  attention  from  the  seat 
■of  the  disease.  It  requires  at  first  blood-letting,  and  then  the  fre- 
quent use  of  laxatives,  with  repeated  blisters. 

When  upon  this  subject,  it  may  not  be  improper  to  mention, 
that  a  young  practitioner  may  mistake  spasmodic  affections,  or 
colic  pains,  for  puerperal  inflammation  ;  for  in  such  cases  there  is 
often  retching  and  sensibility  of  the  muscles,  which  renders  pres- 
sure painful.  But  there  is  less  heat  of  the  skin,  the  tongue  is 
moist,  the  pulse,  though  it  may  be  frequent,  is  soft,  the  feet  are  of- 
ten cold,  the  pain  has  great  remissions  if  it  do  not  go  ofTcomplete- 
ly,  there  is  little  fulness  of  the  belly,  and  the  patient  is  troubled 
with  flatulence.  It  requires  laxatives,  antispasmodics,  anodyne 
clysters,  and  friction  with  camphorated  spirits.  If  these  means  do 
not  give  speedy  relief,  then  we  use  the  lancet.  Blood  drawn  in 
this  disease,  after  it  has  continued  for  some  hours,  even  when  the 
woman  is  not  in  childbed,  is  sizy,  and  it  is  always  so  in  the  puer- 
peral, as  well  as  the  pregnant  state,  although  the  woman  be  well., 


CHAP.  XVI. 

Of  Puerperal  Fever. 

Puerperal  fever  begins  sometimes  in  an  insidious  manner, 
without  that  shivering  which  usually  gives  intimation  of  the  ap- 
proach of  a  serious  malady.  In  other  cases,  the  shivering  is  per- 
ceived, and  varies  considerably  in  degree,  being  either  slight  or 
pretty  severe.  The  first  symptoms,  independent  of  the  shivering, 
are  frequency  of  pulse,  oppression,  nausea,  or  retching,  pain  in  the 
head,  particuluarly  over  the  eye-brows.     The  night  is  passed  with 


550 

iittle  sleep,  much  confusion,  and  occasionally  some  delirium.  It 
must  not,  however,  be  unnoticed,  that  in  many  instances,  there  is 
no  headach  in  any  stage  of  the  disease,  nor  any  sickness  or  vomit- 
ing in  the  beginning.  In  some  the  temper  is,  from  the  first,  un- 
commonly irritable  ;  in  others,  there  is  much  timidity,  or  listless- 
ness,  or  apathy.  Hysterical  symptoms  not  unfrequently  supervene ; 
or  particular  nerves  become  more  sensible  ;  or  organs  of  sense  are 
affected  :  thus  some  imagine  they  hear  the  performance  of  a  piece 
of  music.  From  the  beginning  of  the  attack,  or  very  soon  after- 
wards, pain  is  felt  in  the  belly,  at  first  slight,  but  it  presently  in- 
creases ;  and  in  some  instances,  the  abdomen  becomes  so  tender, 
that  even  the  weight  of  the  bed-clothes  is  productive  of  distress. 
A  general  fulness  of  the  belly  accompanies  this  from  the  first,  and 
it  usually  increases  pretty  rapidly,  and  may  proceed  so  far  as  to 
make  the  patient  nearly  as  large  as  she  was  before  delivery,  and 
in  such  cases,  the  breathing  becomes  very  much  oppressed  :  in- 
deed, in  every  instance,  the  respiration  is  more  or  less  affected, 
the  free  action  of  the  abdominal  muscles,  which  are  concerned  in 
that  function,  being  productive  of  pain.  The  degree  of  pain,  its 
seat,  and  period  of  accession,  vary  in  different  cases.  In  some,  it 
evidently  begins  in  the  uterus,  never  going  entirely  off,  yet  being 
subject  to  severe  exacerbation,  accompanied  with  a  sense  of  bear- 
ing down.  The  uterine  region  is  painful,  particularly  toward  one 
side.  The  os  uteri,  if  examined,  is  not  much  more  sensible  than 
unual.  There  is  generally  pain  in  the  back.  In  other  cases,  it  is 
first  felt  about  the  lower  ribs,  on  one  side,  and  is  accompanied  by 
cough,  the  belly  is  tumid  and  tender  when  pressed,  but  excepting 
then,  or  when  the  patient  turns,  she  complains  little  of  it.  Some- 
times severe  pain,  like  spasm,  attacks  the  iliac  region,  and  extends 
down  the  thigh,  and  toward  the  bladder  and  pubis.  The  face  is 
sometimes  flushed  at  first,  or  the  cheeks  are  suffused,  but  the 
countenance,  in  general,  is  pale  and  ghastly,  the  eyes  are  without 
animation,  and  the  lips  and  angles  of  the  eyes  are  white.  When 
the  face  is  flushed,  the  cheeks  are  generally  covered  with  a  broad 
patch  of  deep  red,  whilst  the  brow  and  other  parts  are  cadaverous, 
or  covered  with  perspiration.  The  whole  features  indicate  anxie- 
ty, if  not  terror,  and  great  debility.     Vomiting  occasionally  occurs 


551 

at  the  very  commencement,  and  in  that  case  it  is  bilious.  In  the 
course  of  the  disease,  it  sometimes  becomes  so  frequent,  that  noth- 
ing will  stay  in  the  stomach  ;  and  towards  the  conclusion  of  the  fe- 
ver, the  fluid  thrown  up  is  dark  coloured,  and  frequently  foetid* 
This  is  a  symptom,  which,  so  far  as  I  have  observed,  always,  if  it 
do  not  proceed  from  a  morbid  structure,  indicates,  in  whatever  dis- 
ease it  occurs,  an  entire  loss  of  tone  of  that  organ.  But  to  proceed 
with  the  history.  There  is  great  dejection  of  mind,  languor,  with 
general  debility  of  the  muscular  fibres,  and  the  patient  lies  chiefly 
on  her  back  ;  or  there  is  so  much  listlessnes^,  that  she  sometimes 
makes  little  complaint.  The  skin  is  not  very  hot,  but  is  rather 
clammy  and  relaxed.  The  tongue  is  pale  or  white  at  first,  but 
presently  becomes  brown,  and  uniformly  aphthae  appear  in  the 
throat,  and  extend  down  the  oesophagus,  and  over  all  the  inside  of 
the  mouth.  From  the  irritability  of  the  stomach  and  bowels,  it  is 
probable  that  these  organs  participate  in  the  tender  state  ;  and  from 
the  cough  which  is  excited,  the  upper  part  of  the  larynx  seems  al- 
so to  be  affected.  It  has  already  been  mentioned,  that  from  the 
first  the  pulse  is  very  frequent,  and  is,  at  that  period,  fuller  than  in 
simple  peritoneal  inflammation,  but  it  soon  becomes  feeble.  The 
thirst  is  not  always  great,  at  least  the  patient  is  often  careless  about 
drink.  The  bowels  are  often  at  first  bound  ;  but  afterwards,  espe- 
cially about  the  third  day,  they  usually  become  loose,  and  the  stools 
are  dark,  foetid,  and  often  frothy.  This  evacuation  seems  to  give 
relief.  It  is  indeed  peculiarly  deserving  of  remark,  that  often  in 
this  disease,  either  from  spontaneous  or  artificial  evacuation,  or 
sometimes,  without  any  perceptible  cause,  there  is  a  delusive  calm, 
and  the  patient  is  supposed  to  be  better;  but  in  such  cases,  I  can- 
not say  I  ever  remember  to  have  found  a  corresponding  improve- 
ment in  the  pulse,  and  therefore  I  placed  no  reliance  on  the  appa- 
rent relief.  The  urine  is  dark  coloured,  has  a  brown  sediment, 
and  is  passed  frequently,  and  with  pain.  The  lochial  discharge  is 
diminished,  and  has  a  bad  smell,  or  is  changed  in  appearance,  or 
gradually  ceases ;  and  it  is  observable,  that  the  re-appearance  of 
the  lochia,  if  they  had  been  suppressed,  is  not  critical.  The  se- 
cretion of  milk  stops,  and  the  patient  inquires  very  seldom  about 
the  child.     In  some  case?,  I  have  met  with  pleuritic  symptoms. 


552 

As  the  disease  advances,  the  pulse  becomes  more  frequent  and 
weaker,  or  tremulous.  In  bad  cases,  the  swelling  of  the  belly  in- 
creases rapftjiy ;  but  the  pain  does  not  always  keep  pace  with  the 
swelling,  being  sometimes  least  when  the  swelling  is  greatest,  and 
in  the  end,  it  generally  goes  entirely  off.  The  breathing  becomes 
laborious,  in  proportion  as  the  belly  enlarges.  The  strength  sinks, 
the  pulse,  always  frequent,  becomes  weak  and  tremulous ;  the 
throat  and  mouth  become  sloughy ;  perhaps  the  stools  are  passed 
involuntarily,  hiccup  sometimes  takes  place,  and  the  patient  usu- 
ally dies  about  the  fifth  day  of  the  disease,  but  in  some  cases  not 
until  the  fourteenth  ;  in  others  so  early  as  the  second  day.  In  some 
instances,  death  is  preceded  by  low  delirium,  or  stupor.  In  others, 
the  mind  continues  unimpaired  till  within  a  few  minutes  of  disso- 
lution, and  the  patient  is  carried  off  after  a  fit  of  a  convulsive  kind. 

This  fever  attacks  generally  on  the  second  or  sometimes  on  the 
third  day  after  delivery,  but  it  has  also  occurred  so  late  as  after  a 
week.  The  earlier  it  attacks,  the  greater  is  the  danger,  and  few 
women  recover  who  have  the  belly  much  swelled. 

On  dissection,  there  is  found  in  the  abdomen,  a  considerable 
quantity  of  fluid,  similar  to  that  met  with  in  peritonitis.  The  omen- 
tum and  peritoneum  are  inflamed  in  a  variable  degree  ;  sometimes 
considerably,  sometimes  very  slightly,  and  gangrene  is  unusual. 
The  swelling  is  neither  proportioned  to  the  inflammation  nor  effu- 
sion, nor  in  every  instance  dependant  on  these,  but  on  that  infla- 
tion of  the  bowels  which  results  from  the  relaxation  of  the  muscular 
fibres  of  the  bowels,  which  is  so  common  in  the  puerperal  state, 
particularly  in  puerperal  disease.  The  uterus,  although  sometimes 
the  first  seat  of  the  pain,  and  occasionally  found  considerably  in- 
flamed, yet  in  general  is  not  more  affected  than  the  intestines.  Iu 
some  cases,  the  thoracic  viscera  are  inflamed. 

It  is  most  frequent,  and  most  fatal,  in  hospitals.  In  private  prac- 
tice it  is  less  malignant,  though  still  very  dangerous.  It  is  sometimes 
epidemic,  but  I  do  not  know  that  it  has  ever  appeared,  as  a  very 
prevailing  epidemic,  in  this  city,  [Glasgow]  ;  nor  have  I  been  able 
except  in  one  season  to  trace  the  contagion  from  one  woman  to 
another.  In  hospitals,  it  has  conspicuously  appeared  as  a  conta- 
gious disease.     There  has  been  much  dispute  whether  the  conta- 


55$ 

jgion  was  one  sui  generis,  or  that  of  typhus  or  erysipelas,  or  hospital 
gangrene;  or  if  the  disease  depended  on  some  noxious  state  of  the 
atmosphere,  conjoined  with  the  absorption  of  putrid  matter.  The 
disease  appears  to  depend  on  inflammation  of  the  peritoneum,  con- 
joined with  the  operation  of  some  debilitating  poison,  more  or  less 
contagious.  It  is  not  connected  with  the  state  of  the  labour,  except 
in  so  far  as  that  hemorrhage  seems  to  predispose  to  it ;  hut  when 
epidemic,  it  occurs  after  a  rapid  and  easy,  as  well  as  after  a  more 
painful  labour. 

It  is  important  to  distinguish  this  disease  from  simple  peritonitis, 
which  may  generally  be  done  by  attention.  In  puerperal  fever,  the 
abdominal  pain  is  seldom  the  most  prominent  symptom,  unless  it 
begin,  like  severe  after-pains,  with  distinct  remissions.  There  is 
more  despondency,  debility,  and  headach ;  less  heat  of  the  skin, 
less  thirst,  and  less  flushing  of  the  face.  In  the  peritoneal  inflam- 
mation, the  pain  in  the  belly  usually  increases  rapidly  after  it  be- 
gins, and  the  swelling  increases  along  with  it.  Pressure  gives  very 
great  pain.  The  fever  is  inflammatory.  Inflammation  of  the  uterus 
has  its  proper  symptoms. 

This  disease  is  dangerous,  in  proportion  to  the  malignancy  of 
the  cause,  and  the  situation  of  the  patient.  All  writers  agree,  that 
in  hospitals  it  is  peculiarly  fatal,  and  that  few  recover  from  it.  In 
private  practice,  the  disease  is  milder,  but  still  it  is  most  formid- 
able. With  regard  to  the  best  mode  of  treatment,  there  has  been 
a  gixdt  difference  of  opinion,*  which  partly  depends  on  giving  the 


*  Dr.  Denman,  Vol.  II.  p.  493,  considers  puerperal  fever  as  contagious.  He 
strongly  advises  early  bleeding,  giving  an  emetic  or  antimonial,  so  as  to  vomit, 
purge,  or  cause  perspiration ;  and  if  this  do  good,  he  repeats  the  dose,  and 
vises  clysters,  fomentations,  leeches,  and  blisters.  He  gives  an  opiate  at  night  and 
a  laxative  in  the  morning ;  or,  if  there  be  great  diarrhoea,  he  employs  emollient 
clysters.    The  strength  is  to  be  supported  by  spt.  ether  nit.  or  other  cordials. 

Dr.  Leak,  Vol.  II.  trusts  much  to  blood-letting ;  if  the  patient  be  sick  he  gives 
a  gentle  vomit ;  if  not,  laxatives,  and  then  antimonials  ;  applies  blisters,  and  in 
the  end  restrains  purging  with  opiates,  and  prescribes  bark. 

Dr.  Gordon,  p.  77,  et  seq.  depends  on  early  and  copious  blood-letting,  taking 
;\t  first  from  20  to  24  ounces,  and  purges  with  calomel  and  jalap.  He  is  regu- 
lated rather  by  the  period  of  the  disease  than  the  State  of  the  pulse,  bleeding;', 
though  it  be  feeble, 

71 


554 

name  of  puerperal  fever  to  different  disorders.     1  am  sorry  that  I 
find  it  much  easier  to  say,  what  remedies  have  failed,  than  what 

Dr.  Butter  purges  and  bleeds  only  where  there  is  well  marked  inflammation, 
•and  is  satisfied  often  with  taking  only  three  ounces  of  blood  at  a  time,  when 
there  is  an  exacerbation. 

Dr.  Manning  very  rarely  bleeds,  but  trusts  to  emetics  and  purges,  and  employs 
Dr.  Denman's  antimonial,  which  is  two  grains  of  tartar  emetic,  mixed  with  ^ij  of 
crabs'  eyes,  and  the  dose  is  from  three  to  ten  grains. 

Dr.  Walsh  forbids  venesection,  and  advises  emetics,  followed  by  opiates,  and 
cordials. 

Dr.  Hulme  trusts  to  clysters,  purges  and  diaphoretics,  and  does  not  bleed  unless 
there  be  pain  in  the  hypogastrium,  accompanied  with  violent  stitches,  and  a  re- 
sisting pulse.     Even  then  he  bleeds  sparingly. 

M.  Doulcet  advises  repeated  emetics,  followed  by  oily  potions,  and  bark,  com- 
bined with  camphor. 

Mr.  Whyte  is  against  bloed-letting.  He  gives  at  first  a  gentle  emetic,  followed 
by  a  laxative  and  diaphoretics.  Then  he  gives  bark,  with  vitriolic  acid,  and  sup- 
ports the  strength. 

Dr.  Joseph  Clark  trusts  chiefly  to  saline  purges  and  fomentations. 

Dr.  John  Clarke,  in  his  excellent  Essays,  forbids  venesection,  and  advises  bark 
as  freely  as  the  stomach  will  bear  it.  Opium  is  also  to  be  given,  together  with  a 
moderate  quantity  of  wine,  along  with  sago.  If  there  be  much  purging,  the 
bark  is  to  be  omitted,  till  some  rhubarb  be  given,  or  a  vomit,  if  there  be  little 
pain  in  the  belly. 

Dr.  Kirkland  bleeds  only  if  the  patient  have  had  little  uterine  discharge,  and 
the  pulse  indicate  it.     He  employs  laxatives,  and  in  the  end  bark  and  camphor. 

Dr.  Hull  considers  this  disease  as  simple  peritoneal  inflammation,  which  may 
effect  three  classes,  the  robust,  the  feeble,  and  those  who  are  in  an  interuiediate 
state.  In  the  first  he  bleeds  and  purges,  in  the  second  he  begins  with  emetics 
and  ends  with  bark,  and  in  the  third  he  bleeds  with  great  caution. 

Dr.  Hamilton  advises  puerperal  to  be  treated  as  putrid  fever. 

Guinot,  Allan,  and  others  recommend  carbonate  of  potash,  in  doses  often  or 
fifteen  grains. 

M.  Vigarous  joins  with  those  who  consider  this  as  not  a  fever  siti  generis,  but 
one  varying  according  to  circumstances.  It  frequently  begins,  he  says,  before 
delivery,  but  becomes  formed  about  the  third  day  after  it.  He  has  five  different 
species.  1st.  The  gastrobilious,  proceeding  from  accumulation  of  bile  during 
pregnancy.  The  essential  symptom  of  this  species  is  intense  pain  in  the  hy- 
pogastrium. He  advises  first  ipecacuanha,  which  he  trusts  to  chiefly,  and  then 
clysters,  laxatives,  and  saline  julap.  2d.  The  putrid  bilious.  This  is  occasioned 
by  bleeding,  or  neglecting  evacuants  in  the  former  species ;  or  even  without 
improper  treatment,  the  fever  may  from  the  first  be  so  violent,  that  bilious  mat- 
ter is  absorbed.  It  is  marked  by  great  debility,  small  or  intermitting  pulse, 
tumour  of  the  hypogastrium,  with  sharp  pain  and  putrid  symptoms,  aphthae, 


555 

have  done  good.  I  have  stated,  that  in  peritoneal  inflammation, 
blood-letting  and  laxatives  are  the  principal  remedies  ;  but  in  this 

vomiting,  foetid  stools,  &c.  He  advises  vomits,  laxatives,  and  bark  in  great 
doses,  with  mineral  acids,  and  clysters  containing  camphor.  3d.  The  pituitous 
fever,  attended  with  vomiting  of  pituita.  The  surface  is  pale,  the  pulse  has  not 
the  force  or  frequency  it  has  on  the  former  species,  the  heat  in  general  not  in- 
creased, anxiety,  weight,  and  vertigo,  rather  than  pain  of  head,  often  miliary 
spots,  and  the  usual  symptoms  of  pain  in  the  belly,  and  subsidence  of  the  breasts. 
He  gives  vomits,  and  afterwards  three  or  four  grains  of  ipecacuanha  every  three 
hours.  If  he  uses  purgatives,  he  conjoins  them  with  tonics.  4th.  With  phlogis- 
tic affection,  or  inflammation  of  the  womb,  attended  with  great  weight  about  the 
pelvis,  swelling,  pain,  and  hardness  m-the  lower  belly,  suppression  of  evacua- 
tions, sharp  frequent  pulse,  acute  fever,  and  the  countenance  not  so  sunk  as  in 
the  putrid  disease.  He  advises  venesection,  leeches,  and  low  diet.  The  same 
remedies,  with  blisters  are  to  be  used,  if  pleuritic  symptoms  occur.  5th.  Spora- 
dic fever,  proceeding  from  cold,  passions  of  the  mind,  &c.  Puerperal  fever  he 
considers  as  apt  to  terminate  in  milky  deposits  in  the  brain,  chest,  legs,  &c. 

Dr.  Armstrong  considers  this  fever  as  decidedly  inflammatory,  and  trusts  to 
the  early  use  of  the  lancet  followed  by  a  large  dose  of  calomel,  from  one  scruple 
to  half  a  dram,  with  the  subsequent  assistance  of  infusion  of  senna  with  salts. 

Dr.  Brenan  has  published  a  pamphlet,  recommending,  in  place  of  blood-letting, 
the  free  use  of  the  oil  of  turpentine  internally,  and  the  external  application  to 
the  belly  of  a  cloth  soaked  in  it. 

Mr.  Hey  is  decided  as  to  the  inflammatory  nature  of  the  disease,  and  trusts  en- 
tirely to  the  early  and  free  use  of  the  lancet,  and  the  administration  of  jalap  and 
calomel,  with  other  cathartics,  so  as  to  maintain  a  purging  for  two  or  three  days, 
or  longer,  if  necessary. 

Hufeland  applies  cold  poultices  to  the  abdomen. 

Gardien  admits  6  species.  1st.  Puerperal  fever,  complicated  with  la  fievre 
angiotenique,  or  synocha,  marked  by  the  ardent  symptoms  of  that  fever.  It  is 
more  strictly  inflammatory,  but  is  the  least  frequent  species.  It  is  to  be  treated 
by  strict  antiphlogistic  regimen.  Venesection  is  only  allowable  in  the  most 
robust  and  plethoric.  A  dozen  of  leeches  applied  to  the  vulva  or  anus  are  safer. 
Lactation  is  the  best  remedy,  and  the  surest  preventive.  2d.  With  la  fievre 
adenomeningee,  or  mucous  fever.  This  is  met  with  often,  and  is  more  slow  and 
insidious :  the  mouth  is  slimy,  and  the  abdominal  pain  is  obtuse.  It  is  to  be 
treated  with  bitters  and  tonics.  3d.  With  la  fievre  meningo-gastrique,  or  bilious 
state,  marked  by  yellow  tinge,  epigastric  pain,  nausea,  bad  taste,  &c.  In  this 
case,  the  violent  abdominal  pain  is  not  always  from  inflammation  It  is  to  be 
treated  by  emetics  or  purgatives,  according  as  the  stomach  or  bowels  seem  most 
affected.  4th.  With  la  fievre  adynamique,  or  putrid  fever.  This  is  the  most 
fatal,  but  most  rare  species,  and  is  marked  by  great  weakness,  small  pulse,  dry 
mouth,  paleness,  and  foetid  diarrhoea.  The  pain  is  less  acute,  and  the  swelling 
is  from  gas.    We  should  neither  use  the  lancet,  nor  active  tonics,  such  as  bark, 


556 

disease  blood-letting  must  be  employed  with  greater  caution.  It 
must  be  resorted  to  very  early,  and  ought  not  to  be  pushed  very 
far.  I  am  quite  convinced  that,  in  simple  peritonitis,  the  lancet  is 
the  anchor  of  hope ;  but,  in  contagious  or  puerperal  fever,  it  must 
be  used  with  more  circumspection,  and  is  less  to  be  depended  on. 
I  am  fully  aware,  from  experience,  of  the  good  effects  of  bleeding 
early  in  typhus  or  contagious  fever;  and,  therefore,  I  have  no 
prejudice  against  the  remedy  in  this  contagious  disease.  I  have, 
on  the  contrary,  used  it  freely  myself,  and  have  known  it  done  so 
by  others ;  and  to  this  free  trial  I  have  been  led,  by  the  respecta- 
ble testimony  to  its  advantage,  as  well  as  the  fatal  issue  of  the  dis- 
ease under  other  treatment.  I  am,  however,  from  observation, 
convinced,  that  if  this  remedy  be  useful,  it  is  in  the  very  early 
stage,  and  that  it  cannot  be  too  soon  employed.  If  the  disease 
have  gained  any  progress,  I  never  have  found  it  useful.  Like 
other  remedies,  particularly  purging,  it  has  been  followed  by  an 
apparent  relief,  but  the  pulse  did  not  come  down,  nor  was  the 
patient  cured.  My  conviction,  therefore,  is,  and  if  an  opinion 
given  in  an  elementary  work  is  to  influence  the  conduct  of  those 
who  read  it,  I  cannot  state  it  without  a  feeling  of  awful  responsi- 
bility, that  the  lancet  is  only  admissible  in  the  very  commence- 
ment of  the  disease,  and  if  decided  benefit  be  not  derived  then, 
we  ought  not  to  repeat  the  evacuation.  It  is  my  duty  to  say,  and 
I  do  it,  considering  the  opposite  sentiments  of  good  judges,  with  a 
sense  of  deference,  that  I  have  never  known  any  patient  recover, 
who  had  been  largely  and  repeatedly  bled,  and  that  all  my  successful 
cases  have  been  amongst  those  who  either  were  not  bled  at  all,  or 
bled  early,  not  above  once,  and  that  not  abundantly.  Were  full  and 
free  depletion  the  proper  remedy  in  this  disease,  and  were  no  mis- 
take committed  by  its  advocates,  in  looking  on  hysteritis  or  peri- 
tonitis as  puerperal  fever,  the  lancet  ought  to  be  more  uniformly 
beneficial.     It  ought  not,  indeed,  to  be  more  useful  than  in  simple 


but  rather  a  kind  of  negative  plan,  giving  lemonade  and  cream  of  tartar,  or 
perhaps  camphor.  5th.  With  la  fievre  ataxique,  or  nervous  symptoms,  as  hic- 
cup, convulsions,  8tc.  6tb.  With  other  local  phlegmasia,  as  of  the  brain,  lungs, 
fcC. 


557 

peritonitis  or  enteritis,  but  if  early  and  vigorously  employed,  it 
should  not  be  much  less  so.     Is  this  the  case  ?* 

On  the  appearance  of  the  disease,  it  will  be  proper  immediately 
to  give  a  smart  dose  of  some  purgative  medicine,  such  as  infusion  of 
senna,  with  the  addition  of  Epsom  salts,  or  calomel,  succeeded  by 
Epsom  salts  ;  afterwards  we  begin  the  use  of  bark,  giving  it  as  libe- 
rally as  the  stomach  will  bear,  or  administering  it  in  the  form  of  a 
clyster ;  at  the  same  time  we  repeat  occasionally  the  aperient 
medicine.  Opiates  given  alter  purgatives,  have  the  effect  of  abat- 
ing irritation  and  pain,  and  of  restruining  immoderate  diarrhoea, 
should  that  come  on.  Diarrhoea  should  not  be  allowed  to  continue 
long,  and  is  always  to  be  restrained,  unless  it  evidently  give  relief, 
and  the  faeces  be  very  foetid.  In  this  case,  calomel  and  diluents 
should  be  employed.  If  there  be  tenesmus,  anodyne  clysters 
should  be  given  after  the  use  of  the  calomel.  In  all  cases,  we  are 
to  attend  much  to  the  bowels,  using  brisk  purgatives  and  clysters, 
where  there  is  no  diarrhoea ;  milder  doses  alternated  with  opiate 
clysters,  where  there  is.  Vomiting  is  to  be  restrained  by  solid 
opium,  and  by  an  opium  plaster  applied  to  the  region  of  the  sto- 
mach: sometimes  saline  draughts  are  of  service.  Nausea  has  been 
supposed  to  indicate  the  necessity  of  an  emetic;  but  if  no  relief  be 
obtained  from  natural  vomiting,  which  most  practitioners  admit,  I 
do  not  see  that  artificial  vomiting  can  be  useful,  nor  does  experience 
support  the  practice.  Anodyne  or  rubefacient  embrocations, 
sometimes  abate  the  pain  in  the  abdomen.  The  repeated  applica- 
tion of  blisters  has  been  extolled  by  some,  but  I  am  much  inclined 
to  concur  with  Dr.  Clarke,  in  thinking,  that  they  rather  excite  an 
injurious  irritation.  Cloths  wet  with  oil  of  turpentine  applied  to 
the  belly4,  produce  less  constitutional  irritation,  and  are  at  least  as 
effectual,  if  not  more  so,  in  relieving  the  internal  pain.  They  are 
generally  more  advantageous  than  fomentations.  The  strength 
should  be  supported  by  light  nourishment,  and  ultimately  by  a 
moderate  proportion  of  wine,   or  other  cordials.     Digitalis  and 

*  The  disease  in  this  country  is  very  generally  a  fever  of  increased  action,  and 
requires  for  its  cure  pretty  copious  depletion.  Bleeding  freely,  purging  actively 
with  the  neutral  salts,  and  blisters  to  the  region  of  the  abdomen,  are  the  reme- 
dies which  have  succeeded  best  in  my  hands.    C. 


558 

other  diuretics  have  been  given,  to  carry  off  the  effused  fluid,  but 
they  have  no  effect.  Some  have  drawn  off  the  fluid  by  paracen- 
tesis. Emetics  and  antimonials,  I  am  afraid,  do  more  harm  in 
general  than  good.  Most  authors,  have  laid  down  distinct  and 
formal  indications  to  be  fulfilled  ;  but  it  is  much  to  be  doubted,  if 
the  means  proposed  be  adequate  to  the  effect  intended  to  be  pro- 
duced ;  or  if  all  the  parade  of  science  has  done  more  than  show, 
that,  with  the  addition  of  remedies  for  removing  particular  symp- 
toms, one  class  of  practitioners  have  trusted  to  the-  lancet  as  the 
chief  engine  of  cure,  and  another  to  the  use  of  bark  and  cordials. 
Peritonitis  is  much  more  frequent  than  puerperal  tevev.(a) 


GHAP.  XVL1. 

Of  Swelled  Leg. 

The  swelling  of  the  inferior  extremity,  in  puerperal  women,  is 
usually  preceded  by  marks  of  uterine  irritation,  and  a  tender  state 
of  the  parts  within  the  pelvis.  About  a  fortnight  after  delivery, 
sometimes  a  little  earlier,  or  even  so  late  as  the  fifth  week,  the  pa- 
tient complains  of  pain  in  the  lower  belly,  increased  by  pressure, 
and  occasionally  has  pain  and  difficulty  in  making  water.  The 
uterine  region  is  somewhat  swelled  ;  the  pulse  is  frequent,  the  skin 

faj  It  is  most  probable  that  the  low  form  of  fever  here  described,  under  the 
name  of  puerperal  fever,  is  comparatively  a  rare  disease  in  the  United  States  of 
America,  even  in  our  large  towns,  but  more  especially  so  in  situations  in  the 
country ;  and  that  what  has  by  some  been  considered  as  that  disease,  and  in  which 
depletion  has  been  found  so  useful,  has  been  a  species  of  peritonitis.  Of  this 
the  Editor  thinks  he  has  known  more  than  one  instance.  On  the  subject  of  fe- 
vers attacking  puerperal  women,  he  would  particularly  recommend  to  the  stu- 
dent, the  attentive  perusal  of  the  excellent  essays  of  Dr.  John  Clarke,  on  the  In- 
flammatory and  Febrile  diseases  of  lying-in  women.  Also,  the  valuable  writings 
of  Gordon  of  Aberdeen  ;  Hey  of  Leeds,  and  Armstrong  of  Sunderland,  on  the. 
puerperal  fever  which  prevailed  as  aji  epidemic  in  those  places. 


559 

hot,  the  thirst  increased,  and  these  symptoms  are  often  preceded 
by  shivering.  Stiffness  and  pain  are  now  felt  in  one  of  the  groins, 
near  the  passage  of  the  round  ligament,  or  the  exit  of  the  tendon 
of  the  psoas  muscle,  or  in  some  cases  about  the  origin  of  the  sar- 
torius  and  rectus  muscles.  The  pain  is  attended  with  swelling, 
and  these  two  symptoms  may  proceed  gradually  down  the  limb; 
but  more  frequently,  pain  is  felt  suddenly  in  the  calf  of  the  leg,  or 
at  the  knee,  near  the  insertion  of  the  sartorius  muscle,  and  is  most 
acute  in  the  course  of  that  muscle ;  it  also  darts  down  to  the  heel. 
Within  twenty-four  hours  after  the  pain  is  felt,  the  limb  swells,  and 
becomes  tense  :  it  is  hot,  but  not  red ;  it  is  rather  pale  and  some- 
what shining.  The  swelling  sometimes  proceeds  from  the  groin 
downwards  ;  in  other  cases,  it  is  first  perceptible  about  the  calf  of 
tb.3  leg,  and  proceeds  upwards.  It  generally  procures  an  abate- 
ment of  the  pain,  but  does  not  remove  it.  On  the  contrary,  the 
patient  cannot  move  the  leg,  and  it  is  tender  to  the  touch.  The 
inability  to  move  it,  however,  does  not  depend  altogether  on  the 
pain,  but  also  on  a  want  of  command  over  the  muscles.  The  pulse 
is  very  frequent,  being  often  140  in  the  minute,  and  generally  is 
small  and  feeble,  but  sharp  ;  the  tongue  is  white  and  moist,  the 
countenance  has  a  pale  chlorotic  appearance,  the  thirst  is  consid- 
erable, the  appetite  is  lost ;  the  bowels  are  either  bound,  and  the 
stools  clay-coloured,  or  they  are  loose,  and  the  stools  very  foetid 
or  bilious.  The  urine  is  muddy  ;  the  lochial  discharge  sometimes 
stops,  or  becomes  foetid  ;  in  other  cases  it  is  not  at  all  affected. 
The  nights  are  spent  without  sleep,  and  the  patient  perspires  pro- 
fusely. AJ1  the  parts  within  the  pelvis  are  tender,  and  the  os  ute- 
ri is  open,  but  not  more  painful  when  touched,  than  the  sides  or 
the  vagina  or  the  internal  muscles. 

The  period  at  which  the  swelling  reaches  the  acme  is  various, 
but  often  it  is  accomplished  in  twenty-four  or  forty-eight  hours. 
It  seldom  makes  the  limb  above  double  its  usual  size.  Gener- 
ally in  ten  days,  sometimes  in  even  two  or  three,  the  febrile  symp- 
toms, swelling,  &c.  abate  ;  but  they  may  be  more  protracted,  and 
they  rarely  go  off  entirely,  for  a  length  of  time.  When  they  go 
off,  the  patient  is  left  feeble,  and  the  limb  stiff,  weak,  and  often,  for 
a  time,  powerless*     Tn  the  course  of  the  cure,  we  frequently  frel 


660 

hard  bumps  in  different  parts  of  the  limb,  especially  on  its  back 
and  inside.  These  are  not  glands  ;  some  consider  them  as  indu- 
rated lymph,  others  as  muscular  contractions.  At  the  top  of  die 
thigh,  the  inguinal  glands  are  often  felt  swelled,  even  at  the  begin- 
ning of  the  complaint ;  but  in  some  cases,  I  have  found  them  not 
at  all  affected. 

If  the  skin  be  punctured  no  serum  is  effused,  at  least,  not  in  the 
same  way  as  in  anasarca,  and  the  swelling  is  not  increased  in  a  de- 
pending posture. 

In  some  cases  the  disease  begins  like  rheumatism,  affecting  the 
back  and  hip  'p'mt.(b)  Then  the  upper  part  of  the  thigh  becomes 
painful  and  swelled,  and  next  the  calf  of  the  leg  suffers  ;  sometimes 
the  limb  at  first  feels  colder  than  the  other.  Occasionally  the  dis- 
ease is  very  mild,  and  attended  with  little  swelling.  This  is  more 
apt  to  be  the  case  when  it  is  late  of  occurring,  and  is  vigorously 
attacked  at  first. 

In  some  instances,  the  patient  has  been  sensible  of  the  pain 
which  expelled  the  child,  rushing  violently  down  the  leg.  After 
a  short  time  it  has  abated,  but  about  the  usual  period  this  disease 
has  appeared. 

In  one  or  two  instances,  suppuration  has  taken  place  :  mortifica- 
tion has  also  happened. 

If  the  disease  run  its  usual  course,  it  is  always  a  length  of  time 
before  the  patient  recover,  for  the  swelling  does  not  go  soon  entire- 
ly away,  and  the  strength  is  long  of  returning.  In  some  instances, 
the  limb  remains  permanently  swelled  and  feeble. 

After  one  leg  has  been  affected,  and  even  before  the  complaint 
has  completed  its  course  there,  the  other  may  become  diseased  ; 
and  this  has  no  influence  on  the  progress  of  the  first.  The  second 
attack  is  sometimes  the  worst  of  the  two,  owing,  perhaps,  to  the 
previous  debility.     A  coldness  is  often  felt  in  the  second  leg,  be- 

(b)  It  is  an  opinion  entertained  by  some  respectable  and  experienced  practi- 
tioners, that  this  disease  is  in  fact,  a  variety  of  rheumatism,  and  is  to  be  manag- 
ed on  the  general  plan  of  treatment  that  is  found  to  be  successful  in  rheumatic 
fever.  After  the  inflammatory  stage  is  over,  it  is  by  them  considered  as  running 
into  the  chronic  state  of  rheumatism,  and  to  be  treated  accordingly  by  the  re- 
medies appropriated  to  that  form  of  disease. 


fore  the  paroxysm  comes  on,  and  pain  in  the  belly  precedes  the 
attack.  The  first  leg  may  be  a  second  time  attacked.  In  one 
instance,  both  of  the  inferior  and  of  the  superior  extremities,  were 
successively  attacked.  The  affection  of  the  arm  was  preceded 
by  pain,  feeling  of  weight,  and  swelling  of  the  lateral  part  of  the 
thorax  and  back.  In  this  case  the  lady,  after  severe  uterine  he- 
morrhage, had  a  smart  attack  of  hysteritis,  which  required,  but 
yielded  completely  to,  the  usual  depleting  plan.  In  a  day  or  two 
afterwards  this  disease  took  place. 

This  is  not  generally  a  fatal  disease,  but  it  is  tedious,  and  is  of- 
ten accompanied  with  hectic  symptoms.  Death,  however,  may 
be  caused  by  suppuration  or  gangrene  ;  or  by  exhaustion,  proceed- 
ing from  the  violence  of  the  constitutional  disease  ;  or  from  ex- 
ertion made  by  the  patient,  which  has  sometimes  proved  suddenly 
fatal. 

The  production  of  this  disease  does  not  seem  to  depend  on  the 
circumstances  of  the  labour,  for  it  appears  both  after  easy  and  dif- 
ficult deliveries.  Those  who  give  suck,  and  those  who  do  not,  the- 
strong  and  the  weak,  are  affected  by  it.  But  if  it  be  late  of  occur- 
ring, it  is  generally  in  those  who  have  suffered  from  mammary  ab- 
scess. It  has  succeeded  an  abortion,  of  suppression  of  urine,  and  a 
slight  degree  of  it  has  followed  abdominal  pain,  attendant  on  men- 
struation, and  been  repeated  for  one  or  two  periods. 

We  seldom  can  detect  any  apparent  exciting  cause,  but,  when 
•we  can,  it  is  generally  cold ;  standing  for  instance,  on  a  cold  or 
damp  floor.  I  am  inclined  to  consider  the  cause  to  be  an  irritated 
or  slightly  inflamed  state  of  the  parts  within  the  pelvis,  which 
sometimes  produces  merely  a  stiffness  and  swelling  at  the  passage 
of  the  round  ligament,  sometimes  an  irritation  of  the  nerves  which 
pass  to  the  leg.  Puzos  and  Levret  consider  the  disease  as  pro- 
ceeding from  a  depot  of  the  milk.  Most  modern  writers  attribute 
it  to  an  affection  of  the  lymphatics,  which  are  ruptured,  or  have 
their  circulation  interrupted  by  swelling  of  the  inguinal  glands.  Dr. 
Hull  considers  the  disease  as  an  inflammatory  affection,  suddenly 
succeeded  by  effusion.  I  refer,  for  a  view  of  the  different  opinions, 
to  his  Treatise  on  Phlegmatia  Dolens.  The  disease  seems  to  con- 
sist partly  in  inflammation,  and  partly  in  nervous  irritatign,  pro- 


562 

ducing  both  pain,  and  a  temporary  species  of  palsy  :  and  the  cure 
consists  in  lessening  the  one,  and  allaying  the  other. 

The  treatment  naturally  divides  itself  into  that  of  the  limb,  and 
that  of  the  constitution. 

Our  first  object  is  to  check  the  disease  within  the  pelvis*  For 
this  purpose,  leeches  ought  to  be  applied  to  the  groin,  and  we 
should  immediately  open  the  bowels  with  a  purgative.  A  small 
blister  should  then  be  applied  to  the  grain,  or  sinapisms  may  be 
applied  to  the  groin,  inside  of  the  thigh,  and  near  the  knee 
on  the  leg,  and  afterwards  tloth.%  wet  with  tepid  solution  of  ace- 
tate of  lead,  or  with  warm  vinegar.fej-  These  means  may  pre- 
vent the  swelling,  or  render  it  milder.  If  the  disease  have  al- 
ready taken  place  in  the  limb,  gentle  friction,  with  warm  oil,, 
anodyne  balsam,  or  camphorated  oil  will  be  useful,  and  should  be 
frequently  repeated.  Fomentations  sometimes  give  relief,  but  al- 
so in  other  cases,  are  rather  disagreeable.  The  bowels  should  still 
be  kept  regular,  but  the  patient  is  not  to  be  purged.  Opiates  are 
useful,  to  allay  irritation.  When  the  acute  symptoms  are  over,  we 
endeavour  to  remove  the  swelling,  and  restore  the  tone  of  the  part,. 
by  friction  with  camphorated  spirits,  and  the  use  of  the  flesh  brush, 
and  a  roller  applied  round  the  limb.  The  liberal  use  of  solution  of 
cream  of  tartar,  is  also  in  many  cases  of  service.  If  the  disease 
threaten  to  be  lingering,  small  blisters  may  be  applied  to  the  groin, 
and  different  parts  of  the  limb.     If  much  weakness  of  the  limb 

Ccj  It  is  the  practice  at  one  of  the  bvst  regulated  lying-in  hospitals*  in  London, 
to  apply  flannel,  well  soaked  in  hot  vinegar,  to  the  groin  of  the  affected  limb,  as 
veil  as  to  the  limb  itself;  and  it  is  asserted,  that  no  other  remedies  beyond  those 
necessary  to  keep  the  bowels  open,  are  ever  used.  [Vide  Vol.  V.  of  Lond.  Med. 
and  Phys.  Journ.]  The  editor  can,  from  experience,  add  his  testimony  in  favour 
of  the  beneficial  effects  of  this  treatment. 

Dr.  John  Clarke,  recommends  laying  the  whole  leg  affected,  in  a  soft  poultice, 
made  as  follows :  To  a  peek  of  well  dried  bran,  he  adds  an  ounce  of  hot  olive  oii; 
and  a  pint  of  strong  soap  lees ;  these  bein  well  mixed  tog-ether,  says  the  Doctor,, 
form  a  poultice,  which  in  these  cases  may  be  used  with  the  greatest  advantage  ; 
it  has  the  good  effect  of  keeping  up  a  gentle  perspiration,  and  forms  the  softest 
pillow  which  can  be  imagined,  never  failing  to  bring  relief. 

Dr.  llosack  of  New  York,  in  this  disease,  strongly  recommends  the  exhi- 
bition of  a  combination  of  squills  and  calomel,  which  he  thinks  has  often  pvc, 
duced  the  best  effects, 


5BS 

remain,  the  cold  bath  is  proper,  or  sometimes  a  hath  of  warm  set* 
water. 

Besides  these  means,  we  must  also  employ  remedies  for  abating 
the  fever,  and  constitutional  affection.  At  first  we  use  saline 
draughts,  but  these  are  not  to  be  often  repeated,  and  must  not  be 
given  so  as  to  procure  much  perspiration.  In  a  short  time  they 
should  be  exchanged  for  hark,  sulphuric  acid,  and  opiates,  which 
tend  to  diminish  the  irritability.  In  the  last  stage  we  give  a  mo- 
derate quantity  of  wine.  When  the  pain  shifts  like  rheumatism, 
bark,  and  small  does  of  calomel  are  useful.  If  the  uterine  dis- 
charge he  foetid,  it  is  proper  to  inject  tepid  water,  or  infusion  of 
camomile  flowers  into  the  vagina.  Exposure  to  cold,  during  the 
first  stage  of  recovery,  may  cause  a  relapse.  The  treatment  thus 
consists  chiefly  in  palliating  symptoms,  and  supporting  the  strength. 
I  cannot,  however,  agree  with  those  who,  in  the  very  outset  of  the 
disease,  give  wine  liberally,  as  there  certainly  does,  at  that  time, 
exist  an  inflammatory  tendency.  The  diet  should  be  light  and  nu- 
tritious.* 


CHAP.  XVIII. 

Of  Par ali/sis. 

Some  women  after  delivery,  lose  for  a  time  the  power  of  the  in- 
ferior extremities,  although  they  may  have  had  a  very  easy  labour. 
This  paralysis  may  exist  in  different  degrees,  and  in  some  cases 
the  muscles  are  painful.  Sometimes  it  is  attended  with  retention 
pf  urine.    It  is  not  accompanied  with  any  cephalic  symptoms.    In 

*  I  have  met  with  but  two  cases  of  this  strange  affection,  which  I  treated,  very 
successfully,  by  copious  bleeding,  by  very  active  purging,  and  by  blisters  applied 
to  the  groin,  and  extending  up  the  abdomen.  In  these  cases  there  was  every  ap- 
pearance of  high  inflammatory  action,  accompanied  with  much  pain.  If  the  pre- 
ceding remedies  should  fail,  and  the  disease  run  on  obstinately  to  the  second 
stage,  I  would  recommend  large  doses  of  opium  to  allay  the  pain,  and  calomel  in 
tbe  ordinary  quantity,  with  a  view  of  exciting  salivation.     C. 


564 

general,  the  disease  wears  off  in  a  few  weeks.  Friction,  the  shower- 
bath,  tonics,  and  gentle  exercise  on  crutches,  are  the  means  of  cure. 
The  bowels  are  also  to  be  kept  open. 

After  a  severe  or  instrumental  delivery,  the  woman  may  coin- 
plain  of  excessive  pain  about  the  loins  and  back,  attended  with 
lameness  or  even  palsy.  This  is  sometimes  a  very  tedious  com- 
plaint, but  usually  it  is  at  last  removed.  A  roller  firmly  applied, 
and  anodyne  embrocations,  relieve  the  pain  ;  at  a  more  advanced 
period,  sea-bathing  is  proper.* 

Hemiplegia  may  attack  women  in  the  puerperal  state,  as  well  as 
at  other  times.  It  proceeds  from  the  same  cause,  and  requires  the 
same  treatment  as  usual.  If  death  takes  place,  blood  is  found  ex- 
travasated  in  the  brain. 


CHAP.  XIX. 

Of  Puerperal  Mania  and  Phrenitis. 

All  women,  in  the  puerperal  state,  are  more  irritable,  and  more 
easily  affected,  both  in  body  and  mind,  than  at  other  times,  and 
some  even  become  delirious.  The  period  at  which  this  mental 
disease  appears  is  various,  but.  it  is  seldom  if  ever  sooner  than  the 
third  day,  often  not  for  a  fortnight,  and  in  some  cases  not  for  se- 
veral weeks  after  delivery.  It  usually  appears  rather  suddenly,  the 
patient  awakening,  perhaps,  terrified  from  a  slumber ;  or  it  seems 
to  be  excited  by  some  casual  alarm.  She  is  sometimes  extremely 
voluble,  talking  incessantly,  and  generally  about  one  object,  sup- 
posing, for  example,  that  her  child  is  killed,  or  stolen ;  or,  although 
naturally  of  a  religious  disposition,  she  may  utter  volleys  of  oaths, 
with  great  rapidity.     In  other  cases,  she  is  less  talkative,  but  is 

*  Active  purging  is  very  useful  in  this  disease.  I  have  also  known  much  good 
'o  be  derived  from  blisters  to  the  sacrum.    C. 


565 

anxious  to  rise  and  go  abroad.  It  is  not,  indeed*  possible  to  de-- 
scribe  the  different  varieties  of  incoherence,  but  there  is  oftcner  a 
tendency  to  raving  than  melancholy.  She  always  recognises  sur- 
rounding objects,  and  either  answers  any  question  put  to  her,  or 
becomes  more  exasperated  by  it.  She  can  by  dint  of  perseverance, 
or  by  proper  management,  be  for  a  time  interrupted  in  her  madness, 
<or  rendered  in  some  degree  obedient.  In  some  instances,  she  rea- 
sons, for  a  little,  pretty  correctly  on  her  insane  idea.  The  eye  has 
a  troubled  appearance,  the  pulse  when  there  is  much  nervous  irri- 
tation, or  bodily  exertion,  is  frequent,  but  it  is  not  in  general  per- 
manently so,  though  it  is  liable  to  accelerations ;  the  skin  is  some- 
times rather  hot,  the  tongue  white  ;  the  secretion  of  milk  is  often, 
but  not  always,  diminished ;  and  the  bowels  are  usually  costive. 
There  is  seldom  permanent  headach ;  but  this  symptom  is  some- 
times produced  pretty  severely  by  attempts  to  go  to  stool,  if  ac- 
companied by  tenesmus,  or  by  efforts  to  void  urine  in  strangury. 
In  some  instances  the  patient  recovers  in  a  few  hours,  in  others  the 
mania  remains  for  several  weeks,  or  even  some  months;  but  I 
believe  it  never  becomes  permanent,  nor  does  it  prove  fatal,  unless 
dependent  on  phrenitis.  Venesection  has  been  advised  in  this  dis- 
ease ;  and  its  propriety  will  depend  on  the  presence  of  symptoms 
of  determination  to  the  head,  indicated  by  pain  or  heaviness,  and 
by  the  state  of  the  vascular  system,  with  regard  to  increased  action, 
and  the  evolution  of  heat.  Where  there  is  little  febrile  affection,  I 
agree  with  those  who  consider  it  as  hurtful,  or  at  least  as  useless.  In 
every  case  we  may  apply  leeches  to  the  temples,  open  the  bowels 
with  a  smart  purgative,  keep  the  surface  gently  moist,  by  means  of 
saline  julap,  and  afterwards  allay  irritation  with  liberal  doses  of 
camphor.  Blisters  have  by  some,  for  whose  opinion  I  have  much 
regard,  been  considered  as  useless,  or  detrimental ;  but  I  am  confi- 
dent I  have  seen  them  do  good,  after  they  had  discharged  freely. 
Opium  is  a  very  doubtful  remedy,  it  oftener  makes  the  patient  rest- 
less than  procures  sleep  ;  but  in  the  wane  of  the  disease,  it  does  in 
some  cases  agree  with  the  patient,  and  is  productive  of  great  benefit. 
There  is  sometimes  considerable  difficulty  in  keeping  the  patient 
in  bed,  and  making  her  take  either  food  or  medicine.  It  is  there- 
fore in  such  instances  of  ffreat  advantage  to  have  earlv  recourse  to 


566 

fl&  Strait  waistcoat,  which  not  only  commands  the  patient,  but  lends 
to  make  her  exercise  sell-control.  In  the  whole  course  of  the  dis- 
ease, the  greatest  attention  must  be  paid  to  the  bowels.  Often  the 
patient  voids  both  urine  and  fjeces  without  telling,  not  from  being 
unable  to  retain  them,  but  from  inattention  or  perversity.  The 
mind  is  not  at  first  the  subject  of  management,  but  in  the  progress 
of  the  complaint,  it  may  by  prudent  efforts  be  aided  in  convales- 
cence, by  cheerful  conversation,  light  reading,  music,  and  after- 
wards by  daily  walking  and  change  of  scene.* 

Some  are  peculiarly  liable  to  this  disease  after  delivery,!  in  con- 
sequence of  the  irritable  state  of  the  nervous  system  at  that  time. 
In  such  cases,  the  patient  ought  to  be  bled  occasionally  during 
pregnancy,  and  particularly  toward  its  conclusion  ;  unremitting  at- 
tention should  especially  be  paid  to  the  state  of  the  alvine  discharge, 
which  I  am  disposed  to  consider  as  of  the  utmost  importance. 
She  must  be  carefully  watched  after  parturition.  Every  irritation 
must  be  removed,  every  source  of  alarm  or  agitation  obviated,  and 
the  camphorated  julap  with  laxatives  will  be  proper  remedies, 
these  being  the  most  powerful  means  of  diminishing  the  excessive 
irritability  of  the  nervous  system.  It  is  impossible  to  be  too  vigi- 
lant of  the  state  of  the  bowels,  either  in  a  prophylactic  or  curative 
view.   The  diet  is  also  to  be  regulated.   If  the  patient  do  not  sleep 

*  In  the  management  of  this  disease  \vc  are  to  observe  the  same  rules  as  are 
■applicable  to  mania  generally.  It  would  seem,  however,  to  be  more  frequently 
attended  with  extreme  nervous  irritation,  than  inflammatory  action.  In  the  for- 
mer state  I  have  seen  the  most  manifest  advantage  from  large  and  repeated  doses 
of  the  tincture  of  hops,  where  opium  only  aggravated  the  symptoms.  In  the  latter 
state  we  should  bleed  and  purge  as  long  as  there  is  increased  excitement.  Blisters 
to  the  head,  and  to  the  extremities,  in  cither  state  will  be  beneficial.  They  will 
alike  allay  nervous  irritation,  or  subdue  inflammatory  action,  and  thus  produce 
calmness  and  ease.  They  are  often,  especially  in  mania,  if  applied  in  the  proper 
condition  of  the  system,  which  is  after  the  excitement  is  a  little  reduced  by  pre- 
vious blood-letting,  the  beat  of  our  anodynes.     C. 

I  Gardien  denies  that  this  disease  depends  on  the  puerperal  state,  but  says  it  is 
to  be  attributed  to  moral  causes,  as  jealousy,  fright,  &c.  He  advises  a  blister  to 
be  applied  to  the  neck  j  or  if  the  lochia  be  obstructed,  leeches  to  be  applied  to 
the  vulva.  A  scruple  of  colocynth  mixed  with  some  bland  substance,  as  lard,  has 
been  recommended,  to  be  rubbed  on  the  abdomen  three  times  a  day,  to  little 
purpose  1  fear. 


5S7 

well,  hyoscyamus  should  be  given.  It  rs  often  of  service  to  get  (ho 
patient  up  as  soon  as  can  be  clone  with  safety,  and  have  the  mind 
occupied  with  such  amusements  and  pursuits  as  keep  it  equally 
exercised,  without  risking  irritation. 

There  is  a  variety  of  this  disease,  in  which  we  find  the  patient, 
very  soon  after  delivery,  complains  of  restlessness,  or  rather  ina- 
bility to  sleep,  The  head  is  slightly  pained,  there  is  a  feeling  of 
unusual  muscular  weakness,  the  pulse  very  little  quicker  than  it 
ought  to  be.  Then,  rather  rapidly,  the  symptoms  become  more 
marked,  the  pulse  becomes  very  frequent,  the  skin  hot,  the  face 
flushed,  the  hearing  acute,  the  eyes  suffused  and  sensible  to  light, 
the  eyelids  heavy.  There  is  a  sense  of  tightness  in  the  throat,  or 
suffocation ;  the  feeling  of  muscular  weakness  is  converted  into  a 
degree  of  paralytic  debility;  the  head  is  acknowledged  to  be  pain- 
ed, but  sometimes  only  a  very  indistinct  and  varying  account  can 
be  got  of  the  sensation.  There  is  thirst,  the  bowels  are  costive,  and 
the  secretion  of  milk  goes  on.  There  is  no  apparent  mental  de- 
rangement, only  the  patient  is  generally  very  dull  or  still,  though 
sometimes  irritable.  If  the  disease  be  not  attacked  vigorously,  the 
paralytic  symptoms  increase  ;  the  pulse  becomes  very  slow,  and  in 
many  instances  even  death  might  follow.  By  instant  venesection,  to 
a  considerable  extent,  all  the  febrile  symptoms  subside,  the  skin  be- 
comes cooler,  the  flushing  goes  off,  the  pulse  falls  from  perhaps  130 
to  SO  or  lower,  and  the  patient  says  that  she  nowT  can  open  her  eyes 
freely,  and  feels  relieved  from  wreight  in  her  head,  which  she  re- 
members to  have  had,  although  before  bleeding  she  perhaps  wrould 
not  admit  its  existence.  In  a  few  cases,  by  full  purging  and  blister- 
ing the  head,  she  is  restored  at  once  to  health.  But  more  fre- 
quently the  recovery  is  partial.  She  complains  still  of  muscular 
weakness,  sometimes  of  her  head,  and  often  of  extreme  acuteness 
of  hearing,  or  sensibility  to  light ;  and  the  mind  is  affected  in  so 
far,  that  she  doubts  the  identity  of  her  child ;  or  becomes  suspicious 
of  her  friends;  or  impressed  with  the  idea  of  approaching  evil ; 
or  indifferent  about  every  thing.  The  appetite  is  generally  keen. 
This  state,  by  attention  to  the  bowels,  regulation  of  the  mind, 
change  of  scene,  or  inducement  to  moderate  but  renewed  exertion^ 
a:oes  off,  although  sometimes,  not  for  many  months. 


668 

Melancholy  usually  comes  on  later  than  furious  delirium.  The 
disease  differs  nothing  in  appearance  and  symptoms  from  melan- 
choly madness  occurring  at  other  times.  It  is  obstinate,  but  gene- 
rally goes  off  after  the  child  is  weaned,  and  the  strength  return?. 
It  is  therefore  proper  to  remove  the  child,  and  send  the  patient  to 
the  country  as  soon  as  possible.  In  some  instances,  both  kinds  of 
madness  seem  to  be  dependent  on  a  morbid  irritation,  such  as  in- 
flammation of  the  mamma,  he.  Here  our  attention  must  be  di- 
rected to  the  cause. 

Inflammation  of  the  brain  usually  appears  still  earlier  than  de- 
lirium, from  irritation.  It  may  be  caused  by  determination  of 
blood  to  the  head,  or  preternatural  irritability  of  the  sensorium,  or 
may  occur  in  consequence  of  a  constitutional  tendency  to  mania. 
It  must  be  distinguished  from  puerperal  delirium  which  is  seldom 
dangerous,  whilst  this  is  a  most  fatal  disease.  It  generally  appears 
within  the  third  day  after  parturition,  but  it  may  also  take  place 
later.  The  pulse  usually  continues  frequent  from  the  time  of 
delivery.  The  patient  does  not  sleep  soundly,  and  indeed  is 
watchful.  She  soon  complains  of  throbbing  within  the  head,  or  in 
the  throat,  or  ears  ;  then  of  confusion,  hears  acutely,  dislikes  the 
light,  and  speaks  in  a  hurried  manner,  and  often  is  unusually  inte- 
rested about  some  trifle.  Then  all  at  once  furious  delirium  comes 
on ;  she  talks  rapidly  and  vociferously,  the  eyes  move  rapidly,  are 
wild  and  sparkling,  and  very  sensible  to  the  light.  This  state  may 
continue,  with  little  interruption,  till  symptoms  of  compression  ap- 
pear, or  there  may  be  a  short  interval  of  reason,  but  presently  the 
furor  returns,  and  alternates  perhaps  with  sullenness.  The  case  is 
in  these  respects  modified  according  to  the  inflammation;  for  some- 
times it  comes  on  rapidly  and  to  a  great  extent,  at  other  times  it 
proceeds  more  slowly.  The  lochia  are  not  suppressed,  nor  are  the- 
bowels  bound,  but  the  secretion  of  milk  ceases.  In  three  or  four 
days,  she  becomes  paralytic  in  one  side,  and  then  sinks  into  a  low 
comatose  state ;  the  extremities  becomes  cold,  the  breathing  labo- 
rious, and  sometimes  convulsions  precede  death.  This  disease 
requires  the  prompt  and  early  use  of  the  antiphlogistic  treatment, 
general  and  local  blood-letting,  the  use  of  purgatives,  and  the  ap- 
plication of  a  blister  to  the  scalp.     The  inflammatory  symptoms 


569 

being  subdued,  the  delirium  abates,  or  goes  off,  by  the  use  of  re- 
medies formerly  pointed  out. 


CHAP.  XX. 

OfBronchocele. 

Swelling  of  the  thyroid  gland  takes  place,  so  much  more  fre- 
quently after  parturition,  than  under  other  circumstances,  that  it 
,jnay  with  propriety  be  noticed  here.  It  appears  within  a  few  days 
after  delivery,  and  is  often  attributed  to  exposure  to  cold.  In 
other  cases,  the  woman  feels,  during  labour,  as  if  something  had 
given  way  about  the  throat.  It  may  remain  long  in  an  indolent 
and  stationary  state,  being  productive  either  of  no  material  incon- 
venience, or  only  of  a  slight  difficulty  of  swallowing.  In  other  in- 
stances, it  augments  in  size,  and  becomes  dangerous  from  its  pres- 
sure on  the  neighbouring  parts ;  or  it  inflames,  forms  a  large 
abscess,  and  bursts.  Enlargement  of  the  left  lobe  is  more  dan- 
gerous than  that  of  the  right.* 

*  There  is  an  intimate  connexion  between  the  thyroid  gland  and  the  brain.  It 
is  well  known,  that,  very  generally,  one  of  the  most  remarkable  symptoms  of 
bronchocele  is  a  gradual,  though  certain,  decay  of  the  intellectual  faculties.  This 
is  strikingly  exemplified  in  the  Cretans  of  the  Alps.  The  goitre,  with  this 
miserable  race  of  people,  is  commonly,  if  not  always,  attended  with  idiotism.  In 
the  lower  animals,  if  the  gland  be  removed,  a  train  of  nervous  affections  will 
speedily  follow,  and  finally  fatuity,  or  a  total  extinction  of  mind.  This  has  been 
proved  by  a  series  of  experiments,  made,  as  I  have  understood,  by  the  celebrated 
Mr.  Cooper  of  London.  As  soon  as  I  heard  of  these  facts,  it  occurred  to  me  as 
being  not  at  all  improbable,  that  one  of  the  hitherto  unknown  uses  of  this  organ, 
might  be  to  stay  the  circulation  in  cases  of  undue  determination  of  blood  to  the 
head.  I  was  assisted  to  this  inference  by  the  recollection  of  having  seen  it 
somewhere  remarked,  that  in  the  cases  alluded  to,  the  gland  is  uniformly  swelled 
more  or  less  with  blood.  If,  as  it  now  seems  to  be  admitted,  that  the  brain  ac- 
quires a  certain  proportion  of  blood  for  the  regular  performance  of  its  functions,. 
and  that  these  will  be  equally  impaired  by  any  excess  or  deficiency  of  it,  we  can 

73 


570 

Various  remedies  have  been  employed,  such  as  burnt  sponge, 
calomel,  muriate  of  lime,  &ic,  but  these  have  seldom  much  effect. 
The  immediate  application  of  leeches,  followed  next  day  by  the 
use  of  cold  water,  to  the  part,  repeated  blisters,  and  long  con- 
tinued friction,  are  more  useful.  If  the  tumour  threaten  to  en- 
large, which  it  often  does,  after  every  succeeding  pregnancy,  or 
even  independent  of  gestation,  it  has  been  proposed  to  extirpate 
the  tumour,  or  to  tie  the  arteries  going  to  it.  If  there  be  a  ten- 
dency to  suppuration,  it  ought  to  be  encouraged,  and  treated  on 
general  principles. 


CHAP.  XXL 

Of  Diarrhcea. 

If  the  patient  have  been  costive  before  delivery,  large  masses 
of  faeces  may  come  down  afterwards,  producing  violent  pains  in 
the  belly,  piles,  tenesmus,  or  uterine  hemorrhage  j  or  the  same 
cause  may  excite  diarrhoea  with  the  passage  of  scybala.  Both 
states  require  the  use  of  gentle  laxatives.  Diarrhoea  may  also  oc- 
cur without  previous  costiveness;  the  stools  are  then  foetid  or 
bilious.  In  this  case  the  diet  is  to  be  strictly  regulated;  gentle  laxa- 
tives are  to  be  first  given  to  evacuate  the  offensive  matter,  and  then 
opiates  are  to  be  immediately  resorted  to.  If  neglected,  great  weak- 


have  no  difficulty  in  conceiving  how  the  brain  becomes  affected,  either  by  an  en- 
largement or  total  extirpation  of  the  gland. 

With  respect  to  the  production  of  puerperal  bronchocele  we  have  an  obvious 
explanation.  During  parturition,  and  particularly  if  it  be  laborious,  there  is 
very  frequently  an  efflux  of  blood  to  the  head,  and,  as  may  be  observed,  a  con- 
siderable distention  of  the  thyroid  gland.  By  this  distention,  which  occasion- 
ally is  so  great,  as  to  induce  the  woman  to  believe,  «  that  sometMng  has  given 
way  about  her  throat"  the  gland  is  relaxed  ;  it  receives  thereby  a  larger  quan* 
tity  of  blood,  which  necessarily  nourishes  a  morbid  growth  of  the  part.    C. 


571 

ness,  uterine  hemorrhage,  or  other  serious  consequences  may  be 
produced.  When  it  is  accompanied  with  bilious  vomiting,  and 
cramps  or  spasms,  opiates  are  the  principal  remedy,  and  these 
must,  if  vomited,  be  given  in  the  form  of  clysters. 


CHAP.  XXII. 

Of  Inflammation  of  the  Mamma,  and  Excoriation  of  the  Nipples. 

Inflammation  of  the  mamma  may  take  place  at  any  period  of 
nursing,  but  is  most  readily  excited  within  a  month  after  delivery. 
It  may  be  caused  by  the  direct  application  of  cold,  retention  of  the 
milk  in  consequence  of  sore  nipples,  mechanical  injury,  mental 
causes,  or  it  may  occur  in  that  febrile  state,  called  weed.  In  gen- 
eral, the  inflammation,  however  extensive  it  may  afterwards  be- 
come, is  at  first  confined  to  a  small  spot.  It  may  take  place  in  the 
cellular  substance  alone,  or  it  may  affect  the  gland  ;  it  may  be  at- 
tended with  much  general  swelling  of  the  breast,  or  the  tumour 
may  be  very  circumscribed  ;  it  may  run  its  course  rapidly,  or  very 
slowly ;  and  when  abscess  forms,  and  the  integuments  burst,  we 
may  have  matter  alone  discharged,  or  there  may  be  a  slough  of 
considerable  magnitude  found  within  the  abscess.  This  proceeds 
from  the  destruction  of  one  or  more  of  the  glands,  which,  if  the 
inflammation  run  high,  do  not  suppurate  but  die.  Usually,  there 
is  a  considerable  degree  of  fever  attending  the  complaint,  and  the 
pain  is  often  severe,  especially  when  the  breast  is  extensively  af- 
fected. It  is  a  very  difficult  thing  to  prevent  this  inflammation 
from  ending  in  suppuration.  It  is  to  be  attempted,  however,  by 
purgatives,  and  the  application  of  a  tepid  poultice  of  bread  and 
milk,  or  cloths  moistened  with  tepid  water.  Cold  solution  of  ace- 
tate of  lead,  alone,  or  preceded  by  leeches,  has  been  recommend- 
ed, but  I  have  long  been  obliged  to  abandon  this  practice,  from 


572' 

the  little  success  which  attended  it.*  If  it  was  ever  useful,  it  was 
only  in  slight  cases,  where  it  was  adopted  early,  and  the  disease 
was  chiefly  in  the  cellular  substance  near  the  surface.  If  there 
be  only  a  little  diffused  fulness,  with  some  degree  of  pain,  gentle 
friction  with  warm  oil  is  useful.  If  the  breast  be  distended  with 
milk,  it  will  be  proper  to  have  a  little  taken  away  occasionally, 
provided  this  can  be  done  easily,  and  without  increasing  the  pain. 
Our  object  in  doing  so  is  to  diminish  the  tension,  and  prevent  far- 
ther irritation  from  accumulation  in  the  vessels.  The  breast  is 
also  to  be  carefully  supported,  and  indeed  the  patient  will  be  ea- 
siest in  bed.  When  the  pain  becomes  throbbing,  a  warm  bread 
and  milk  poultice  is  proper  to  assist  the  suppurating  process.  Af- 
ter matter  is  formed,  it  ought  to  be  freely  let  out,  by  an  opening 
of  sufficient  size,  provided  there  be  no  appearance  of  the  abscess 
bursting  soon  of  its  own  accord.  This  prevents  insinuation  of 
matter  in  the  cellular  substance  of  the  breast.  If  the  puncture  be 
followed  by  a  troublesome  oozing  of  blood  from  the  wound,  dry 
lint  and  compression  must  be  used.  In  one  instance,  I  knew  the 
hemorrhage  prove  fatal.  After  the  abscess  bursts,  or  is  opened, 
there  is  for  some  time  a  discharge  of  purulent  matter,  which  fre- 
quently is  mixed  with  milk  ;  then  the  surrounding  hardness  grad- 
ually abates.  The  poultice  may  be  continued  for  several  days, 
as  it  promotes  the  absorption  of  the  indurated  substance  ;  but  if  it 
fret  the  surface,  and  encourage  a  kind  of  phagedenic  erosion,  it  is 
to  be  exchanged  for  mild  dressings.  A  little  fine  lint  is  to  be  ap- 
plied on  the  aperture,  but  not  so  firmly  as  to  confine  the  matter ; 
and  over  this,  a  cloth  spread  with  spermaceti  ointment ;  great  at- 
tention is  to  be  paid  to  the  evacuation  of  the  matter,  and  the  pre- 
vention of  sinuses.  Fungus  at  the  orifice  of  the  sinuses  requires 
an  escharotic. 

In  some  instances  the  milk  soon  returns,  and  the  patient  can 
nurse  with  the  breast  which  was  affected,  but  more  frequently  it 
does  not,  and  the  child  is  brought  up  on  one  breast.  It  may  even 
be  requisite,  if  the  fever  and  pain  be  great,  and  the  secretion  of 
milk  much  injured,  to   give  up  nursing  altogether. 

*  I  know  of  nothing  so  good  in  these  cases,  as  bathing  the  breast  with  am'u- 
ture  of  laudanum,  brandv,  an.d  hartshorn.  C. 


573 

It  sometimes  happens,  if  the  constitution  be  scrophulous,  tlio 
-mind  much  harassed,  or  the  treatment  not  at  first  vigilant,  that  a 
very  protracted,  and  even  fatal  disease  may  result.  The  patient  has 
repeated,  and  almost  daily  shivering  fits,  followed  by  heat  and  per- 
spiration, and  accompanied  with  induration  or  spasm  in  the  breast. 
She  loses  her  appetite,  and  is  constantly  sick.  Suppuration  slow- 
ly forms,  and  perhaps  the  abscess  bursts,  after  which  the  symptoms 
abate,  but  are  soon  renewed,  and  resist  all  internal  and  general  rer 
medies.  On  inspecting  the  breast,  at  some  point  distant  from  the 
original  opening,  a  degree  of  oedema  may  be  discovered,  a  never- 
failing  sign  of  the  existence  of  deep-seated  matter  there,  and,  by 
pressure,  fluctuation  may  be  ascertained.  This  may  become  dis- 
tinct very  rapidly,  and  therefore  the  breast  should  be  examined 
6arefully,  at  least  once  a-day.  Poultices  bring  forward  the  abscess, 
but  too  slowly  to  save  the  strength,  and,  therefore,  the  new  ab- 
scess, and  every  sinus  which  may  have  already  formed  or  existed, 
must  be,  at  one  and  the  same  time,  freely  and  completely  laid 
open ;  and  so  soon  as  a  new  gland  suppurates,  the  same  operation 
is  to  be  performed.  If  this  be  neglected,  numerous  sinuses  form, 
slowly  discharging  foetid  matter,  and  both  breasts  are  often  thus 
affected.  There  are  daily  shiverings,  sick  fits,  and  vomiting  of 
bile,  or  absolute  loathing  at  food,  diarrhoea,  and  either  perspiration,, 
or  a  dry,  scaly,  or  leprous  state  of  the  skin,  and  sometimes  the  in- 
ternal glands  seem  to  participate  in  the  disease,  as  those  of  the 
mesentery,  or  the  uterus  is  affected,  and  matter  is  discharged  from 
the  vagina.  The  pulse  is  frequent,  and  becomes  gradually  feebler; 
till,  after  a  protracted  suffering  of  some  months,  the  patient  sinks. 
It  is  observable,  that  often  in  these  cases,  which  seem  to  depend 
on  a  constitutional  cause,  and  when  there  is  great  debility,  the  si- 
nuses heal  rapidly,  after  being  laid  open,  but  a  new  gland  instantly 
begins  to  suppurate.  Internal  remedies  cannot  be  depended  on 
here,  for  they  cannot  be  retained.  If  they  can  be  taken,  they  are 
those  of  a  tonic  nature  that  we  would  employ,  with  opiates  to  abate 
diarrhoea. 

The  diet  must  be  as  nourishing  as  possible,  and  a  liberal  allow- 
ance of  that  kind  of  wine  which  agrees  best  with  the  stomach  must 
be  given.  Our  prognosis,  indeed,  will  be  more  or  less  favourable, 
according  to  the  nourishment  which  can  be  taken..    The  main  se- 


574 

curity,  however,  of  the  patient  rests  on  an  early  stop  being,  if  pos- 
sible, put  to  the  disease,  by  opening  the  abscesses  or  sinuses  freely, 
and  before  the  constitution  have  been  injured,  or  undermined  by 
repeated  paroxysms  of  fever.  It  ought  to  be  impressed  on  the 
mind  of  every  practitioner,  and  every  patient,  that  unremitting  at- 
tention should  be  paid  early  to  the  state  of  the  breast,  and  no  deep- 
seated  collection  of  matter  ever  be  allowed  to  remain  unopened ; 
for  we  do  not  know  where  the  mischief,  if  allowed  to  continue, 
may  end.  This  is  urgently  necessary,  in  proportion  to  the  severi- 
ty of  the  constitutional  symptoms. 

There  are  indolent  cases,  where  sinuses  form  and  give  little  or  no 
trouble,  except  by  the  dressing  or  attention  they  require.  Timid 
patients  will  not  submit  to  have  these  opened ;  but  the  cure  will 
be  hastened,  if  that  were  agreed  to.  In  the  former  state  it  was, 
from  the  affection  of  the  general  health,  and  the  state  of  the  pa- 
tient, imperative.  In  this  indolent  state,  where  the  patient  is  in 
pretty  good  health,  and  walking  about,  it  is  proper,  but  neverthe- 
less, more  optional.  Superficial  sinuses  should  be  laid  open.  Those 
which  were  very  deep,  should  either  have  a  counter  opening  made, 
or  a  seton  introduced. 

Sometimes,  although  the  abscess  heal  readily,  and  have  been 
small,  an  induration  remains,  which  either  may  continue  long  in- 
dolent, and  cause  apprehension  respecting  future  consequences,  or 
it  may  occasion  a  relapse.  It  is  to  be  removed  by  gentle  friction 
with  camphorated  spirits  three  times  a-day,  and  the  application,  in 
the  intervals,  of  cloths  wet  with  camphorated  spirits  of  wine,  with 
the  addition  of  a  tenth  part  of  acetum  lythargyri,  or  a  bread  and 
milk  or  cicuta  poultice,  may  be  applied.  In  more  obstinate  cases, 
mercurial  friction,  or  a  gentle  course  of  mercury  may  be  tried, 
but  I  cannot  speak  with  any  confidence  of  the  effect.  The  bowels 
should  always  be  kept  open. 

After  an  abscess  heals,  it  is  not  uncommon  for  the  breast  to 
^well  a  little  at  night  from  weakness,  and  the  same  cause  renders  a 
relapse  easy.  It  is  therefore  proper  to  invigorate  the  system,  and 
defend  the  breast  for  some  weeks  more  carefully  than  usual,  from 
cold.  When  a  relapse  takes  place,  especially  if  the  patient  be  not 
nursing,  the  tumour  is  sometimes  pretty  deep  or  indolent ;  is  for  a 


575 

longtime  hard  to  the  feel ;  and  gradually  extends  more  through  the 
breast,  forming  a  pretty  large  substance,  not  unlike  a  scirrhous  or 
scrophulous  gland.  But,  during  this  time,  suppuration  is  slowly 
going  on,  though  there  may  be  little  pain.  At  last  a  more  active 
change  takes  place,  the  pain  increases,  becomes  throbbing,  the  skin 
grows  red,  and,  finally,  the  abscess  bursts.  This  state  requires  the 
application  of  warm  poultices  and  hot  fomentations. 

Excoriation  of  the  nipple  is  a  very  frequent  affection,  and  often 
excites  that  disease  we  have  just  been  considering.  The  ulcer 
may  be  extensive,  but  superficial  j  or  it  may  be  more  circumscrib- 
ed, but  so  deep  as  almost  to  divide  the  nipple.  When  the  child 
sucks,  the  pain  is  severe,  and  sometimes  a  considerable  quantity  of 
blood  flows  from  the  part.  In  some  instances,  an  aphthous  state  of 
the  child's  mouth  excites  this  affection  :  in  others,  excoriation 
of  the  nipple  affects  the  child.  A  variety  of  remedies  have  been 
employed.  Spirituous,  saline,  and  astringent  lotions,  have  been 
used  previous  to  delivery,  with  a  view  of  rendering  the  parts  more 
insensible  :  they  have  not  always  that  effect,  but  they  ought  to  be 
ined.(d)  When  excoriation  takes  place,  fifteen  grains  of  sulphate 
of  zinc,  dissolved  in  four  ounces  of  rose  water,  form  a  very  useful 
wash,  which  should  be  applied  frequently.  Solutions  of  sulphate 
of  alumine,  acetate  of  lead,  sulphate  of  Copper,  nitrate  of  silver,  &c. 
in  such  strength  as  just  to  smart  a  little,  are  also  occasionally  of 
service  ;  and  it  is  observable,  that  no  application  continues  long  to 
do  good.  Frequent  changes,  therefore,  are  necessary.  The  nip- 
ple should  always  be  bathed  with  milk  and  water,  or  solution  of  bo- 
rax, before  applying  the  child.  When  chops  take  place,  dressing 
the  part  with  lint  spread  with  spermaceti  ointment,  is  sometimes 
of  use.  A  combination  of  white  wax,  with  fresh  butter  or  melted 
marrow,  with  or  without  vegetable  additions,  form  popular  appli- 


(dj  In  one  instance  which  has  been  related  to  me  by  a  respectable  physician 
of  this  city,  the  suction  of  the  nipple  by  a  young  puppy  for  about  one  month 
preceding  parturition,  had  the  most  complete  success  in  preventing  the  exces 
sive  soreness  and  suffering  to  winch  the  lady  had  heen  subjected,  in  consequence 
cf  her  previous  labours.  This,  though  to  some  it  may  perhaps  appear  an  un- 
pleasant preventive,  yet  is  certainly  worthy  of  the  attention  of  those  who  have 
often  experienced  the  extreme  anguish  arising  from  this  variety  of  disease. 


576 

cations.  Stimulating  ointments,  such  as  ung.  hyd.  nit.  diluted  with 
axunge,  are  sometimes  of  service ;  or  the  parts  may  be  touched 
with  burnt  alum.fej 

It  is  often  useful  to  apply  a  tin  case  over  the  nipple,  to  defend 
it,  or  broad  rings  of  lead  or  ivory.  It  is  also  proper  to  make  the 
child  suck  through  a  cow's  teat,  or  an  artificial  nipple,  that  the  ir- 
ritation of  its  tongue  or  mouth  may  be  avoided.  This  often  is  of 
great  service,  but  it  does  not  always  succeed  ;  and  some  children 
cannot  suck  through  it.  The  artificial  nipple  is  preferable  to  the 
cow's  teat.  It  is  made  of  elastic  gum ;  but  a  small  polished  case  or 
nipple,  made  of  wood,  covered  with  any  soft  substance  to  defend 
the  gum,  will  serve  the  purpose.  The  assistance  of  a  nurse  to 
suckle  the  child  through  the  night  is  useful.  But  although  the  nip- 
ples ought  to  be  saved  as  much  as  possible,  yet  if  we  keep  the  child 
too  long  off,  or  permit  the  breast  to  become  much  distended,  in- 
flammation is  apt  to  take  place.  When  all  these  means  fail,  it  is 
necessary  to  take  off  the  child,  as  a  preseverance  in  nursing  ex- 
hausts the  strength,  and  may  excite  fever.  The  part  then  heals 
rapidly. 

Venereal  ulcerations  of  the  nipple  or  areola,  accompanied  with 
swelled  glands  in  the  axilla,  and  a  diseased  state  of  the  child's 
mouth,  require  a  course  of  mercury. 

It  may  be  proper,  before  concluding  this  chapter,  to  add  some 
remarks  on  causes  disqualifying  a  woman  from  nursing.  If  the 
nipple  be  very  flat,  and  cannot  by  suction  be  drawn  out,  so  that  the 
child  can  get  hold  of  it,  the  woman  cannot  nurse.  A  glass  pipe, 
however,  frequently  used,  sometimes  remedies  this  defect.  A  de- 
ficiency of  retentive  power,  so  that  the  milk  runs  constantly  out,  is 
another  disqualification,  and  it  is  not  easy  to  find  a  remedy.  When 
the  milk  disagrees  with  the  child,  having  some  bad  quality,  we  are 
also  under  the  necessity  of  employing  another  nurse.  If  the  mo- 
ther be  very  delicate,  or  be  consumptive,  or  affected  with  obstinate 
melancholy,  or  have  her  eyes  much  inflamed,  or  the  sight  injured 

fej  Richter  recommends  touching  the  ulceration  of  the  nipple  with  the  lunar 
caustic,  and  Dr.  Hartshorne  informs  me  he  has  tried  this  with  success  in  several 
■cases,  where  every  other  application  had  failed  giving  relief.  The  caustic  should 
he  applied  once  every  two  da.vs> 


577 

by  nursing,  or  if  the  secretion  be  very  sparing,  she  mu%t  give  up 
nursing.  Some  delicate  women  suffer  so  much  from  nursing,  that 
chlorotic  or  phthisical  symptoms  are  induced.  In  this  case,  we 
must  take  off  the  child.  Opiates  are  useful,  at  bed  time,  to  procuro 
sleep,  and  the  bowels  are  to  be  kept  open.  Many  women,  after  de- 
livery, are  subject  to  disorders  of  the  alimentary  canal,  especially 
diarrhoea  and  worms.  These  impair  the  health,  and  diminish  the 
secretion  of  milk.  They  are  to  be  treated  with  the  usual  remedies. 
Anasarca,  jaundice,  erysipelas,  &c.  may  also  occur  in  the  puerperal 
state,  and  prevent  nursing.  The  ordinary  methods  of  cure  are  to 
be  employed. 

When  a  woman  weans  a  child,  or  from  the  first  does  not  suckle 
it,  it  is  usual  to  give  one  or  two  doses  of  some  purgative  salt,  by 
way  of  lessening  the  secretion  of  milk.  The  secretion  is  also 
checked  by  keeping  off  the  child  ;  but  if  the  breasts  be  very  much 
distended,  so  much  must  be  taken  away  occasionally,  by  suction, 
or  milking  the  breast,  or  applying  a  warm  glass  bell,  as  relieves  die 
feeling  of  tension  or  pain.  If  this  be  neglected,  inflammation  may 
be  excited. 

Some  women  feel,  after  lying  in,  a  considerable  weakness  or 
sensation  of  want  about  the  belly,  which  is  frequently  increased  by 
nursing.  It  is  often  produced  by  taking  off  the  bandage  too  soon 
from  the  jfcdomen,  which  should  not  be  done  for  a  month  at  least, 
and  is  relieved  by  the  application  of  a  broad  firm  band  round  the 
belly.  When  there  is  constant  aching  in  the  back  and  failure  of  the 
appetite,  nursing  must  be  abandoned. 

Pain  in  the  side,  or  in  the  abdomen,  which  is  sometimes  pro- 
duced by  nursing,  is  often  relieved  by  friction,  warm  plasters,  and 
an  invigorating  plan.  General  weakness  requires  tonics,  which 
must  be  varied. 


CHAP.  XXIIL 

Of  Tympanites. 

In  consequence  of  affection  of  the  menstrual  action,  or  after  con- 
finement, especially  if  the  patient  be  exposed  to  cold,  the  boweh 

74 


578 

'become  inflated,  and  the  belly  is  slowly  distended,  without  pain. 
This  may  also  happen  during  nursing,  or  towards  the  cessation  of 
the  menses,  giving  rise  in  either  case  to  an  idea  that  the  woman  is 
pregnant.  This  complaint  is  not  productive  of  bad  health,  but  oc- 
casionally it  causes  acidity,  and  other  dyspeptic  symptoms,  and  it 
is  moreover  very  unseemly.  The  enlargement  is  always  increased 
about  the  menstrual  period,  if  menstruation  continue.  It  arises 
from  a  relaxation  of  the  muscular  fibres  of  the  intestines,  and  may 
not  only  appear  as  a  peculiar  disease  itself,  but  also  accompany 
many  puerperal  affections,  particularly  of  the  febrile  kind,  although 
there  be  no  inflammation  of  the  bowels. 

It  is  best  prevented  by  keeping  the  bowels  in  a  regular  and  ac- 
tive state,  paying  attention  to  the  application  of  an  abdominal  bind- 
er after  confinement,  and  avoiding  exposure  to  cold,  and  other  ex- 
citing causes  of  disease. 

After  it  has  taken  place,  it  is  exceedingly  difficult  to  accomplish 
a  cure.  Brisk  purgatives,  the  regular  use  of  aperients,  so  as  to  ex- 
cite a  uniform,  but  not  powerful  action,  carminatives,  squills,  tur- 
pentine, mercury,  Harrowgate  water,  stimulating  embrocations,  re- 
gular compression,  tonics,  and  sea  bathing,  have  all  been  tried,  but 
upon  none  of  them  can  I  place  any  great  reliance.  This  disease  is- 
very  apt  to  be  succeeded  by  ascites,  or  ovarian  dropsy. 

Acute  tympanites  accompanied  with  fever,  is  a  more  formidable 
disease.  This  supervenes  soon  after  delivery;  there  is  a  great  de- 
gree of  fever,  increasing  weakness,  and  a  puffy  swollen  state  of  the 
belly,  without  pain;  It  requires  purgatives  and  cordials,  but  is 
generally  fatal,  and  perhaps  is  only  a  modification  of  puerpera^ 
fever. 


CHAP.  XXIV. 

Of  the  Signs  that  a  Woman  has  been  recently  delivered. 

We  discover  that  a  woman  has  been  recently  delivered,  by  find- 
ing that  the  external  parts  are  relaxed,  and  redder,  or  of  a  darker 
colour,  than  usual.    There  is  a  sanguineous  or  lochial  discharge- 


679 

The  uterus  is  enlarged,  and  has  neither  the  shape  of  the  gravid  nor 
unimpregnated  uterus  ;  the  cervix  is  indistinct,  and  the  os  uteri  is 
nearly  circular,  and  will  admit  two  or  more  fingers.  The  abdomen 
is  prominent,  and  the  integuments  relaxed,  wrinkled,  and  covered 
with  light-coloured  broken  streaks.  The  breasts  are  enlarged,  have 
the  areola  very  distinct,  and  contain  milk.  It  is  possible  for  this 
secretion  to  take  place  independently  of  pregnancy,  but  not  with 
the  appearances  just  described. 

By  examination  per  vaginam,  within  a  fortnight  or  three  weeks 
after  delivery,  the  uterus  may  still  be  felt  larger  than  usual,  its  lips 
softer,  and  capable  of  admitting  the  point  of  the  finger  without 
much  difficulty.  The  milk  at  this  period  will  not  have  left  the 
breasts,  which  are  firm,  and  have  a  dark  areola  round  the  nipple. 
A  question  here  occurs,  May  not  all  these  appearances  take  place 
merely  from  hydatids?  I  reply,  that  hydatids  certainly  may  produce 
the  same  effects  with  gestation,  because  they  do  generally  spring, 
from  conception.  It  is,  however,  very  rare  for  the  belly  to  be  en- 
larged to  the  same  degree  as  in  the  end  of  pregnancy,  and  when 
the  mass  is  expelled,  as  it  is  soft,  the  perineum  cannot  be  injured. 
If  then  it  can  in  a  criminal  case  be  proved,  that  the  woman  had  the 
belly  greatly  enlarged,  and  if  afterwards  she  is  found  with  the 
breasts  containing  milk,  the  uterus  large,  and  its  mouth  soft  and 
open,  and  part  of  the  perineum  of  the  fourchette  torn.,  there  can  be 
no  doubt  that  she  has  borne  a  child.  Other  circumstances  may  also 
concur  in  confirming  the  opinion  of  the  practitioner ;  as,  for  in- 
stance, if  the  patient  give  an  absurd  account  of  the  way  in  which 
her  bulk  suddenly  left  her,  ascribing  it  to  a  prespiration,  which 
never  in  a  single  night  can  carry  off  the  great  size  of  the  abdomen 
in  the  end  of  a  supposed  pregnancy. 

Very  contradictory  accounts  have  been  given  by  anatomists,  of 
the  appearance  and  size  of  the  uterus,  when  inspected  at  different 
periods  after  delivery.  If  the  woman  die  of  hemorrhage,  or  from 
any  cause  destroying  her,  soon  after  delivery,  the  uterus  is  found 
like  a  large  flattened  pouch,  from  nine  to  twelve  inches  long.  The 
cavity  contains  coagula  or  a  bloody  fluid,  and  its  surface  is  cover- 
ed with  remains  of  the  decidua.  Often  the  marks  of  the  attach- 
ment of  the  placenta  are  very  visible.     This  part  is  of  a  dark 


580 

colour,  so  that  the  uterus  is  thought  to  be  gangrenous,  by  those 
who  are  not  aware  of  the  circumstance.  The  surface  being 
cleaned,  the  sound  substance  of  the  womb  is  seen.  The  vessels 
are  extremely  large  and  numerous.  The  fallopian  tubes,  round 
ligaments,  and  surface  of  the  ovaria,  are  so  vascular,  that  they  have 
a  purple  colour.  The  spot  where  the  ovum  escaped,  is  more  vas- 
cular than  the  rest  of  the  ovarian  surface.  This  state  of  the  ute- 
rine appendages  continues  until  the  womb  has  returned  to  its  un- 
Impregnated  state. 

A  week  after  delivery,  the  womb  is  as  large  as  two  fists.  At 
the  end  of  a  fortnight,  it  will  be  found  about  six  inches  long,  gen- 
erally lying  obliquely  to  one  side.  The  inner  surface  is  still 
bloody,  and  covered  partially  with  a  pulpy  substance,  like  decidua. 
The  muscularity  is  distinct,  and  the  orbicular  direction  of  the  fibres 
round  the  orifice  of  the  tubes  very  evident.  The  substance  is 
whitish.  The  intestines  have  not  yet  assumed  the  same  order  as 
usual,  but  the  distended  caecum  is  often  more  prominent  than  the 
rest. 

It  is  a  month  at  least,  before  the  uterus  return  to  its  unimpreg- 
nated  state,  but  the  os  uteri  rarely,  if  ever,  closes  to  the  same  de~ 
gree  as  in  the  virgin  state. 

We  know  that  the  woman  has  had  a  recent  miscarriage,  by  the 
State  of  the  breasts,  the  sanguineous  discharge  from  the  vagina,  the 
size  of  the  uterus,  and  the  softness  and  dilatation  of  its  mouth.  Il 
the  woman  die,  the  womb  is  found  enlarged,  its  inner  surface  co- 
vered with  the  decidua,  or  maternal  portion  of  the  placenta.  The 
vessels  are  enlarged,  the  tubes  and  ligaments  very  vascular ;  the 
calyx  of  the  ovum  is  bloody. 

The  appearances  during  life,  or  after  death,  which  occur  from  a 
miscarriage,  may  also  arise  from  the  expulsion  of  hydatids,  which 
■usually  are  produced  by  the  destruction  of  an  ovum. 


AS  our  author  has  not  fully  illustrated  the  mechanism  of  labour, 
as  was  desirable,  in  the  different  presentations  of  the  vertex,  and  as 
an  accurate  and  precise  knowledge  of  the  position  of  the  head  is 
necessary,  preparatory  to  the  proper  application  of  and  action  writh 
the  forceps  or  vectis,  we  have  thought  it  best  to  add  the  descrip- 
tion of  the  passage  of  the  head  through  the  straits  and  cavity  of  the 
pelvis  in  the  six  different  positions  of  the  vertex,  as  minutely  laid 
down  and  detailed  by  Baudelocque  and  Gardien.  To  these  au- 
thors we  must  therefore  acknowledge  our  obligations  for  the  pages 
that  follow  ;  and  we  are  persuaded,  that  to  the  student  and  young 
practitioner  of  midwifery,  they  will  not  be  superfluous,  but  on  the 
contrary,  will  deserve  the  most  serious  attention,  as  a  compass  to 
guide  him  in  his  course  through,  what  would  otherwise  prove,  a 
wilderness  of  doubt  and  uncertainty. 

We  have  also  added  a  table  from  the  last  edition  of  Baude- 
locque's  art  des  accouchemens,  which  shows  the  comparative  fre- 
quency of  the  different  presentations,  [at  least  in  Paris]  and  of 
those  difficult  and  preternatural  cases  which  peremptorily  require 
the  assistance  of  art,  either  by  means  of  the  hand  alone,  or  by  the 
aid  of  instruments. 

It  has  already  been  explained,  that  the  vertex  or  crown  of  the 
head,  the  presentation  of  which  constitutes  the  first  order  of  natu- 
ral labours,  is  recognised  by  die  presence  of  a  round  solid  tumour, 
of  greater  or  lesser  size,  upon  which  we  can  trace  several  sutures 
and  fontanelles. 

But  even  when  the  vertex  presents,  the  sutures  and  fontanelles: 
do  not  always  answer  to  the  same  point ;  which  has  induced  prac- 
titioners of  midwifery  to  distinguish  the  different  positions  of  the 
vertex,  according  to  the  manner  in  which  this  part  presents  at  the 


582 

Superior  strait,  and  which  we  determine  by  the  relative  situation 
of  the  fontanelles,  and  the  direction  of  the  sutures. 

Although  there  is  no  point  of  the  pelvis  to  which  the  posterior 
fontanclle,  which  we  should  always  take  for  our  guide,  may  not 
correspond,  we  may  nevertheless  confine  the  number  of  positions 
to  six  principal  ones.  Indeed,  a  sufficiently  accurate  idea  might 
be  given  of  natural  parturition,  by  describing  a  lesser  number  of 
positions.  But  it  becomes  necessary  to  admit  them  as  above  enu- 
merated, to  explain  fully  those  cases,  where  the  intervention  and 
aid  of  art  becomes  necessary.  For  properly  to  apply  the  forceps, 
and  to  act  with  them  advantageously,  the  accurate  knowledge  of 
these  different  relations  of  the  foetal  head  with  the  pelvis,  as  well 
as  its  progress  through  the  different  stages  of  the  labour,  until  de- 
livered, is  supposed  to  be  well  understood. 

More  clearly  to  comprehend  this  part  of  our  subject,  we  may 
consider  the  circumference  of  the  pelvis  as  divided  into  two  seg- 
ments, or  semi-circumferences,  one  anterior  and  the  other  posterior. 
In  the  three  first  positions,  [which  have  already  been  briefly  enu- 
merated in  a  note  to  Chapter  1st  of  the  2d  Book,  and  which  we 
shall  presently  more  fully  explain]  the  posterior  fontanelle  answers 
to  one,  of  what  we  may  venture  to  term  the  cardinal  points  of  the 
anterior  semi-circumference  ;  in  the  three  last,  the  same  posterior 
fontanelle  answers  to  one  of  the  diametrically  opposite  points  of 
the  posterior  semi-circumference. 

If  we  observe  the  direction  that  the  head  pursues  in  each  of 
these  positions,  when  it  is  expelled  by  the  efforts  of  nature  alone, 
Ave  shall  find,  that  in  each  of  them,  it  offers  some  peculiarities, 
which  it  is  of  importance  to  understand.  The  mechanism  of  these 
different  species  of  labour,  ought  to  be  studied  with  the  greater  at- 
tention, as  it  is  this  knowledge,  which  is  to  guide  the  practitioner 
in  all  his  operations,  in  those  cases  of  labour,  where  malposition 
of  the  head  occurs.     Vide  Chap.  IV.  Book  II. 

First  Position.  In  this  position,  the  posterior  fontanelle  answers 
to  the  left  acetabulum.  The  back  of  the  infant  is  situated  towards 
tlie  anterior  and  left  lateral  portion  of  the  uterus  and  pelvis.  The 
face  and  the  breast  answering  to  their  posterior  and  right  lateral 
portions.     The  feet  and  breech  are  towards  the  fundus  uteri. 


533 

At  the  commencement  oflabour  it  is  frequently  only  the  middle 
portion  of  the  sagittal  suture  which  presents  at  the  centre  of  the  su- 
perior strait.  Whilst  both  the  fontanelles  remain  as  yet  out  of  the 
reach  of  the  finger  in  the  common  examination  ;  we  cannot,  there- 
fore, at  this  period,  accurately  determine  the  precise  position  of 
the-head.  For  although  we  may  ascertain  that  the  sagittal  suture 
is  directed  from  the  left  acetabulum  to  the  right  sacro-iliac  symphy- 
sis, we  are  as  yet  ignorant  whether  the  posterior  fontanelle  is  situ- 
ated in  the  anterior  or  posterior  segment  of  the  pelvis,  and  of  con- 
sequence, whether  the  vertex  presents  in  the  first  or  the  fourth  po- 
sition. The  same  difficulty  presents  in  discriminating  between 
the  2d  and  the  5th  position,  and  between  the  3d  and  the  6th, 
whilst  we  can  merely  reach  the  sagittal  suture. 

In  the  first  period  of  labour,  it  is  commonly  one  of  the  parietal 
bones  which  presents.  As  the  labour  advances,  the  middle  portion 
of  the  sagittal  suture  retires  from  the  centre  of  the  pelvis,  to  give 
place  to  one  of  the  fontanelles;  and  it  is  the  posterior  fontanelle 
that  most  frequently  presents. 

When  the  waters  have  been  discharged,  the  first  contractions  of 
the  uterus  tend,  in  the  natural  progress  oflabour,  to  bend  the  head 
upon  the  breast.  Whilst  this  is  taking  place,  the  posterior 
fontanelle  approaches  nearer  and  nearer  to  the  centre  of  the 
pelvis.  The  head  thus  bent,  continues  to  progress  through  the  ca- 
vity, by  passing  from  before  backwards,  in  order  to  accommodate 
itself  to  the  axis  of  the  superior  strait.  It  continues  to  descend/ 
until  checked  by  the  sacrum,  the  coccyx,  and  the  perinaeum. 

Whilst  the  head  descends  into  the  cavity  of  the  pelvis  in  a  dia- 
gonal direction,  one  of  the  parietal  protuberances  passes  before 
the  left  sacro-iliac  symphysis,  and  the  other  behind  the  right  ace- 
tabulum. 

In  this  position,  it  is  the  right  parietal  bone  which  answers  to 
the  arch  of  the  pubis.  One  of  the  branches  of  the  lambdoidal  su- 
ture answers  to  the  left  limb  of  the  pubis,  and  the  other  branch  is 
directed  towards  the  left  ischiatic  notch.  This  has  been  often  mis- 
taken for  the  sagittal  suture,  and  in  consequence  of  its  direction, 
which  is  from  before  backwards,  it  has  been  supposed  that  the 
head  had  already  performed  its  movement  of  rotation,  by  which 


534 

the  posterior  fontanelle  is  ultimately  brought  under  the  arch  of  the 
pubis. 

The  head  having  arrived  at  the  bottom  of  the  pelvis,  cannot  any 
longer  follow  its  first  direction,  because  it  is  checked  by  the  sa- 
crum and  coccyx.  The  contractions  of  the  uterus  continuing  to 
act  upon  it,  force  the  occiput,  as  it  were,  to  revolve  from  behind 
forwards  upon  the  inclined  plane,  which  the  left  side  of  the  pelvis 
offers,  in  order  to  advance  towards  the  symphysis  of  the  pubis  ; 
whilst  at  the  same  time,  the  face  turns  into  the  hollow  of  the  sa- 
crum, as  it  were  revolving  from  before  backwards  upon  the  inclin- 
ed plane,  which  the  other  side  of  the  pelvis  presents.  If  the  fin- 
gers are  placed  upon  the  posterior  fontanelle,  whilst  the  head  re- 
tains it  lateral  position,  it  may  sometimes  be  perceived  to  perform 
this  movement  on  its  axis  during  a  strong  pain. 

Whilst  the  occiput  approaches  the  arch  of  the  pubis,  the  trunk 
remains  without  motion  in  the  uterus.  This  pivot-like  motion  of 
the  occiput,  depends  solely  upon  the  twisting  of  the  neck.  This 
rotation  being  performed,  the  posterior  fontanelle  is  situated  to- 
wards the  centre  of  the  arch  of  the  pubis,  and  the  anterior  towards 
the  sacrum.  The  sagittal  suture  is  parallel  to  the  great  diameter 
of  the  inferior  strait.  The  branches  of  the  lambdoidal  suture  an- 
swer to  each  side  of  the  pelvis. 

The  chin,  which,  until  this  period,  had  remained  constantly,  ap- 
plied to  the  breast,  begins  to  recede  from  it.  The  occiput  dilates 
the  external  parts,  and  engages  under  the  arch  of  the  pubis,  under 
which  it  revolves,  in  rising  and  approaching  towards  the  abdomen 
of  the  mother.  Whilst  the  occiput  thus  progresses,  the  nape  of 
the  neck,  which  may  be  considered  as  the  centre  of  motion,  re- 
volves under  the  inferior  edge  of  the  arch  of  the  pubis.  In  this 
motion,  the  occiput  passes  over  but  a  small  space,  whilst  the  chin, 
in  describing  a  curve,  progresses  from  the  sacrum  to  the  inferior 
commissure  of  the  labia.  The  expulsive  forces  bear  upon  the  fore- 
head and  upon  the  face,  during  this  period  of  labour,  and  oblige 
the  chin  to  recede  from  the  breast.  The  neck  is  sufficiently  long 
to  allow  the  head  to  be  delivered  without  the  trunk's  advancing.  If 
the  head  in  its  passage  does  not  accommodate  itself  to  this  curve 
line,  above  described,  but  descends  directly  in  the  direction  of  the> 


585 

axis  of  the  superior  strait,  every  effort  bears  upon  the  perinaeum, 
which  is  then  in  danger  of  rupturing  in  its  centre.  If  we  do  not 
succeed  in  obliging  the  head  to  follow  the  direction  above  des- 
cribed, by  applying  pressure  from  behind  forwards,  and  from  the 
perinaeum  upwards,  the  only  means  which  remains  to  prevent  the 
laceration  of  this  part  is  to  apply  the  forceps,  in  order  to  direct 
the  head  forward,  and  thus  oblige  the  chin  to  recede  from  the 
breast. 

Scarcely  is  the  head  delivered,  when  the  face  turns  towards  the 
right  thigh  of  the  woman,  to  which  it  answered  in  the  com- 
mencement of  labour ;  for  it  only  turns  into  the  hollow  of  the  sa- 
crum, in  consequence  of  the  twisting  of  the  neck,  and  resumes  its 
first  position,  as  soon  as  the  neck  is  restored  to  its  former  situa- 
tion. 

When  the  head  is  completely  delivered,  the  shoulders,  which 
had  entered  the  superior  strait  diagonally,  as  well  as  the  head,  turn 
one  towards  the  pubis,  and  the  other  towards  the  sacrum.  The 
left  shoulder,  which  is  towards  the  sacrum,  approaches  the  vulva, 
and  begins  to  be  engaged  there,  whilst  the  right  shoulder  remains 
applied  behind  the  symphysis  of  the  pubis,  until  the  other  appears 
externally ;  which  indicates,  that  when  it  is  proper  to  assist  in  ex- 
tricating the  shoulders,  we  should  act  principally  upon  that  which 
is  placed  posteriorly. 

Such  is  the  progress  of  nature  in  this  species  of  parturition,  as 
every  one  may  convince  himself,  if  he  will  trace  it  step  by  step, 
through  the  course  of  the  labour.  And  in  observing  it,  he  will  be 
able  to  distinguish  three  different  movements.  In  the  first  period, 
the  head  bends  itself  towards  the  breast,  and  progresses  through 
the  cavity  of  the  pelvis.  In  the  second  it  performs  a  motion, 
Which  brings  its  long  diameter  in  the  direction  of  pubis  and  sacrum. 
In  the  third,  the  chin  quits  the  breast,  and  the  occiput  turns  back- 
wards, in  disengaging  itself  from  under  the  pubis. 

The  head  ought  to  present  its  greatest  diameters  to  the  greatest 
diameters  of  the  straits  ;  but  as  it  regards  the  superior  strait,  if 
does  not  present  as  is  commonly  supposed,  its  smallest  diameter 
to  the  smallest  of  that  strait.  Its  smallest  diameter  is  directed 
from  one  sacro-iiiao  symphysis,  to  the  opposite  acetabulum.    The. 

70 


586 

portion  of  the  head  which  passess  between  the  pubis  and  the  sa- 
crum, is  still  narrower  than  that  which  is  termed  its  small  diameter. 

This  species  of  labour  would  always  be  the  most  advantageous, 
if  the  laws  of  nature  were  invariably  carried  into  effect,  but  in  pro- 
portion as  nature  varies  from  the  line  that  has  been  delineated, 
the  labour  becomes  more  and  more  difficult,  and  often  indeed  im- 
possible, without  the  aid  of  art. 

Second  Position.  In  this  position  the  posterior  fontanelle  is 
placed  behind  the  right  acetabulum,  and  the  anterior  is  situated 
before  the  left  sacro-iliac  symphysis,  so  that  the  back  of  the  child 
answers  to  the  anterior  and  right  lateral  portion  of  the  uterus,  and 
of  the  pelvis ;  whilst  the  face,  the  breast,  and  the  knees,  are  situ- 
ated towards  their  posterior  and  left  lateral  portions. 

The  mechanism  of  labour  in  this  position,  is  perfectly  similar  to 
that  of  the  preceding.  As  in  that,  if  the  expulsive  forces  are  di- 
rected in  such  a  manner,  as  to  apply  the  chin  of  the  infant  more  and 
more  to  the  breast,  the  occiput  progresses  during  the  first  period 
through  the  depth  of  the  cavity.  In  the  second  period,  the  occi- 
put slides  from  behind  forwards  upon  the  inclined  plane,  which  is 
presented  by  the  right  side  of  the  pelvis,  in  order  to  place  itself 
under  the  arch  of  the  pubis  ;  whilst  at  the  same  time,  the  face 
turns  into  the  hollow  of  the  sacrum.  In  the  third  period,  the  ex- 
pulsive forces  oblige  the  chin  to  recede  from  the  breast ;  the  oc- 
ciput dilates  the  vulva  as  it  turns  upwards  towards  the  pubis. 
This  movement  of  the  occiput  is  but  inconsiderable  ;  it  does  no- 
thing but  turn  itself,  whilst  the  nape  of  the  neck  revolves  under 
the  superior  part  of  the  arch.  In  order  that  this*  revolving  of  the 
head  backwards,  which  facilitates  its  expulsion  may  take  place,  it 
is  necessary  that  the  face  should  pass  over  a  curve  which  mea- 
sures in  extent  the  whole  length  of  the  sacrum,  to  the  anterior, 
edge  of  the  perinaeum. 

As  soon  as  the  head  is  delivered,  the  face  turns  towards  the 
left  thigh,  to  which  it  primarily  answered.  The  left  shoulder  turns 
towards  the  pubis,  and  the  right  towards  the  sacrum.  This  latter 
alone  advances  until  it  appears  at  the  vulva. 

The  relative  proportions  of  the  diameters  of  the  child,  with 
those  of  the  pelvis,  are  really  the  same  in  this  position  as  in 
the  former.     The  occiput  and  the  face  have  not  a  larger  space  to 


587 

traverse  to  arrive,  the  one  at  the  symphysis  pubis,  and  the  other 
in  the  hollow  of  the  sacrum,  in  the  position  where  the  posterior 
fontanelle  is  situated  towards  the  right  acetabulum,  than  in  that 
where  it  is  placed  behind  the  left.  Hence  it  would  appear,  that 
one  of  these  positions  ought  to  be  as  favourable  as  the  other  to 
the  expulsion  of  the  child.  But  there  are,  notwithstanding,  greater 
difficulties  experienced  in  that  where  the  occiput  is  to  the  right ; 
because  the  rectum,  which  is  placed  on  the  left  side  of  the  sacrum, 
prevents  the  forehead  from  turning  so  readily  into  the  hollow  of 
that  bone. 

Practitioners  have  supposed  that  it  more  frequently  happens  in 
this  position,  than  in  the  preceding,  that  the  direction  of  the  ex- 
pulsive powers,  instead  of  advancing  the  occiput,  as  in  the  natural 
order,  tends  to  throw  it  back  upon  the  shoulders.  What  truth  there 
is  in  this  supposition,  we  shall  not  here  stop  to  investigate. 

Third  Position.  In  this  position  the  posterior  fontanelle  is  behind 
the  symphysis  pubis,  and  the  anterior  before  the  projection  of  the  sa- 
crum. The  back  of  the  infant  is  towards  the  anterior,  and  its  abdo- 
men towards  the  posterior  portion  of  the  uterus.  For  a  long  time  this 
was  considered  as  the  most  common  and  the  most  advantageous  po- 
sition, but  both  of  these  suppositions  are  incorrect;  for  experience  on 
the  contrary  proves,  that  it  is  very  rare ;  so  much  so  indeed,  that  many 
practitioners  who  have  never  met  with  it,  have  absolutely  called  its 
existence  in  question.  Those  who  have  imagined  that  the  occi- 
put constantly  answered  to  the  pubis  from  the  commencement  of 
labour,  have  only  thought  so,  because  they  observed  it  disengage 
itself  in  this  direction  from  the  inferior  strait.  A  regular  examina- 
tion through  the  whole  process,  would  have  taught  them,  that  al- 
though the  occiput  is  expelled  from  under  the  pubis,  it  nevertheless 
enters  the  superior  strait  diagonally.  When  the  occiput  passes 
through  the  superior  strait  directly  behind  the  symphysis  pubis, 
the  long  diameter  of  the  head  is  opposed  to  the  small  diameter  of 
this  strait.  The  difficulty  which  is  experienced  by  the  head  in 
its  passage  must  be  greater,  as  the  friction  must  be  more  consider- 
able. If  no  obliquity  exists,  parturition  may  nevertheless  be  ac- 
complished with  a  sufficient  degree  of  ease ;  because  in  a  well 
formed  pelvis,  the  short  diameter  of  the  strait  is  four  inches,  and 
the  long  diameter  of  the  head  is  no  greater.     If  the  head  engages 


588 

favourably,  it  only  presents  its  height,  or  its  perpendicular  diame- 
ter, because  the  chin  rises  towards  the  breast  of  the  infant,  which 
facilitates  the  expulsion  of  the  head. 

There  are  but  two  periods  to  be  taken  notice  of  in  the  progress 
of  this  species  of  labour ;  the  face  remains  towards  the  perinaeum 
for  some  time  after  the  delivery  of  the  head ;  it  does  not  turn  to 
one  or  other  of  the  thighs,  until  after  the  shoulders,  which  had  en- 
tered the  superior  strait  diagonally,  have  presented  at  the  inferior 
strait,  one  being  towards  the  pubis,  and  the  other  towards  the  sa- 
crum ;  but  they  turn  indifferently  to  one  or  the  other  part  of  the 
pelvis,  because  the  head  has  not  been  obliged  to  perform  the 
pivot-like  motion.  Of  course,  it  is  not  in  our  power  previously  to 
designate,  which  shoulder  will  turn  towards  the  pubis. 

Fourth  Position.  In  this  position  the  anterior  fontanelle  is  be- 
hind the  left  acetabulum,  and  the  posterior  before  the  right  sacro- 
iliac symphysis,  and  the  course  of  the  sagittal  suture  is  obliquely, 
from  the  former  to  the  latter  point.  The  back  of  the  infant  is  to  the 
right  posterior  portion,  and  its  breast,  &tc.  towards  the  left  anterior 
portion  of  the  uterus. 

Although  at  the  commencement  of  labour,  the  posterior" fonta- 
nelle is  placed  towards  the  right  rr.ero-iliac  symphysis,  the  face 
does  not  always  come  out  under  the  arch  of  the  pubis.  We  some- 
times observe,  that  the  occiput  approaches  the  right  acetabulum,  in 
proportion  as  the  head  advances  in  the  pelvis.  When  this  sponta- 
neous conversion  of  the  fourth  to  the  second  position  takes  place, 
it  is  to  be  considered  as  extremely  favourable  for  the  patient.  From 
hence  an  inference  has  been  drawn,  that  when  the  practitioner 
meets  with  this  position,  he  ought  at  the  commencement  of  labour 
to  facilitate  its  progress,  and  lessen  the  sufferings  of  the  female,  when 
the  face  is  turned  towards  the  symphysis  of  the  pubis,  by  making  an 
effort  to  disengage  it  from  that  part,  and  bring  the  occiput  during 
the  pains,  rather  forward  towards  the  pubis,  than  towards  the  sa- 
crum. If  the  membranes  have  not  been  ruptured,  it  is  impossible 
to  touch  the  head  during  the  existence  of  a  pain.  This  conversion 
cannot  be  accomplished  without  risk,  except  we  act  at  the  instant 
of  the  discharge  of  the  waters.  When  nature  spontaneously  pro- 
duces this  conversion  in  the  fourth  and  fifth  positions,  the  same 
change  of  relative  situation  takes  place  in  the  trunk.  We  ought  not, 


589 

therefore,  lo  attempt  producing  it  by  art,  unless  the  child  is  suffi- 
ciently moveable,  to  permit  the  trunk  to  undergo  the  same  changes 
in  situation  as  the  occiput ;  unless  this  were  the  case,  the  neck 
would  suffer  a  twisting,  which  would  amount  to  the  third  of  a  circle. 
It  may  be  important  to  recollect  the  possibility  of  this  conversion, 
in  those  cases  in  which  we  are  obliged  to  apply  the  forceps,  because 
the  mode  of  proceeding  will  be  different  if  that  has  taken  place.  We 
should,  therefore,  before  applying  the  forceps,  endeavour  to  ascer- 
tain whether  or  no  the  face  is  towards  the  pubis. 

If  the  change  of  position,  of  which  we  have  just  spoken,  has  not 
taken  place,  the  delivery  of  the  head  becomes  more  difficult,  be- 
cause, in  the  second  period,  the  face  turns  towards  the  symphysis 
of  the  pubis.  This  part  is  disengaged  with  more  difficulty  from 
under  the  arch  of  the  pubis,  than  the  occiput ;  for  the  arch  has  less 
breadth  in  its  superior  part,  than  the  forehead  and  the  face  of  the 
infant.  The  form  of  the  occiput,  on  the  contrary,  accommodates 
itself  very  well  to  the  arch  of  the  pubis,  under  which  it  turns,  whilst 
the  face  disengages  itself  behind. 

If  in  this  position,  the  contractions  of  the  uterus  are  directed  in 
such  a  manner,  as  to  bear  upon  the  occiput,  it  descends  into  the 
pelvis,  passing  before  the  right  sacro-iliac  symphysis.  When  the 
head  reaches  the  sacrum,  it  can  no  longer  follow  its  first  direction. 
The  contractions  of  the  uterus  oblige  it  to  perform  a  pivot-like  mo- 
tion, which  turns  the  occiput  into  the  hollow  of  the  sacrum,  de- 
scending along  the  inclined  plane  of  the  right  side ;  whilst  at  the 
same  time,  the  forehead  places  itself  under  the  pubis,  sliding  along 
the  inclined  plane,  which  the  left  side  of  the  pelvis  offers.  At  the 
end  of  this  second  period,  the  anterior  fontanelle  is  situated  behind 
the  pubis,  and  the  posterior  towards  the  sacrum. 

In  the  last  period,  the  forehead  cannot  engage  under  the  arch  of 
the  pubis,  as  the  occiput  does  in  the  three  preceding  positions ;  it  is 
obliged  to  ascend  behind  the  symphysis,  to  the  internal  surface  of 
which  it  remains  applied,  whilst  the  posterior  fontanelle  passes  over 
the  length  of  the  sacrum,  the  coccyx  and  the  perinreum,  to  arrive 
at  the  bottom  of  the  vulva.  At  this  moment  the  edge  of  the  peri- 
naeum  is  considerably  stretched,  and  runs  a  greater  risk  of  lacera- 
tion than  in  the  preceding  positions.  The  perinaeum  not  being  ca- 
pable of  remaining  stationary  upon  the  inclined  plane  which  the 


590 

occiput  offers,  retires  suddenly  towards  the  base  of  the  neck  of  the 
infant. 

The  posterior  edge  of  the  perinaeum  becomes  then  the  point  of 
support,  or  axis,  upon  which  the  nape  of  the  neck  revolves,  whilst 
the  occiput  turns  backwards  towards  the  anus  of  the  woman.  In 
proportion  as  the  head  turns  backwards  upon  the  perinaeum,  the 
face  disengages  from  under  the  pubis.  We  observe  successively 
appear  the  forehead,  the  orbits,  the  nose,  the  mouth  and  the  chin. 
As  soon  as  the  chin  appears  externally,  the  face  turns  towards  the 
left  thigh,  to  which  it  primarily  answered.  The  left  shoulder  pre- 
sents afterwards  towards  the  pubis,  and  the  right  towards  the  sa- 
crum. That  which  is  posterior,  disengages  the  first,  the  other  re- 
maining stationary  at  that  time. 

Fifth  Position.  In  this  position  the  anterior  fontanelle  is  behind 
the  right  acetabulum,  and  the  posterior  before  the  left  sacro-iliac 
symphysis.  The  back  of  the  infant  is  towards  the  left  and  posterior 
part  of  the  uterus,  its  breast  and  abdomen  is  towards  the  right  and 
anterior  part.  It  is  not  unfrequently  the  case,  that  the  efforts  of 
nature  alone  are  competent  to  convert  this  position  into  the  first, 
the  occiput  gradually  approaching  towards  the  left  acetabulum,  in 
proportion  as  it  descends  into  the  pelvis.  All  the  observations  that 
have  been  made  on  the  preceding  position,  with  respect  to  attempt- 
ing, by  the  aid  of  art,  what  nature  herself  sometimes  performs,  are 
equally  applicable  to  this  position. 

The  relations  of  the  dimensions  of  the  head  of  the  child  with 
those  of  the  pelvis,  are  absolutely  the  same  in  this  position,  as  in 
the  preceding;  the  face  turns  equally  upwards.  Hence  the  mecha- 
nism of  this  species  of  labour,  is  in  every  respect  similar  to  that  of 
the  preceding  position.  If  every  thing  is  in  the  natural  order,  the 
occiput  descends  into  the  pelvis,  passing  before  the  left  sacro-iliac 
symphysis.  In  the  second  period  it  turns  towards  the  sacrum,  at 
the  same  time  that  the  forehead  turns  towards  the  symphysis  pubis. 
The  presence  of  the  rectum  on  the  left  side  of  the  pelvis,  renders 
this  rotation  more  difficult,  by  preventing  the  occiput  from  turning 
freely  into  the  hollow  of  the  sacrum.  This  position  is  one  of  those, 
in  which  it  is  most  essential  to  evacuate  the  rectum  by  an  enema. 
As  soon  as  the  face  is  disengaged  from  under  the  pubis,  it  turns  to 
the  right  groin.     The  right  shoulder  is  afterwards  directed  towards 


591 

the  pubis,  and  the  left  towards  the  sacrum.     The  latter  alone  ad- 
vances until  it  appears  at  the  vulva. 

Sixth  Position.  In  this  position  the  anterior  fontanelle  is  behind 
the  pubis.  The  sagittal  suture  is  parallel  to  the  smallest  diameter 
of  the  superior  strait.  The  occiput  and  the  back  of  the  infant  is 
towards  the  sacrum. 

This  position  is  the  least  favourable  of  all  those  which  the  occi- 
put can  take.  Not  only  does  the  head  present  its  length  to  the 
smallest  diameter  of  the  superior  strait,  but  also  the  face  is  anterior, 
as  it  regards  the  pelvis,  as  in  the  two  preceding  positions.  Hap- 
pily it  is  the  most  rare  of  all.  The  rounded  form  of  the  head, 
with  difficulty  permits  it  to  remain  fixed  during  labour  against  the 
projection  of  the  sacrum,  so  that  even  supposing  it  should  answer 
to  this  part  of  the  sacrum  at  the  commencement  of  the  labour,  it 
would  soon  turn  to  one  of  its  sides,  which  would  be  better  accom- 
modated to  its  figure.  When  we  happen  to  see  the  face  disengage 
itself  from  under  the  pubis  towards  the  end  of  labour,  we  are  not 
thence  to  suppose,  that  the  head  engaged  in  that  way  in  the  supe- 
rior strait.  Although  in  the  two  preceding  positions,  the  head  tra- 
verses this  strait  in  a  diagonal  situation,  the  face,  which  in  the  first 
period,  was  placed  toward  one  or  other  of  the  acetabula,  turns  by 
a  pivot-like  motion  towards  the  arch  of  the  pubis,  from  under  which 
it  is  delivered. 

We  can  distinguish  but  two  periods  in  this  position.  If  the  ex- 
pulsive forces  of  the  uterus  act  upon  the  occiput  as  occurs  in  the 
natural  order,  it  progresses  through  the  pelvis  before  the  sacrum. 
Whilst  the  forehead  is  applied  against  the  internal  surface  of  die 
symphysis  of  the  pubis,  the  occiput,  which  ought  to  be  delivered 
first,  considerably  distends  the  perinaeum,  passing  over  a  curve  line 
which  extends  from  the  hollow  of  the  sacrum  to  the  lower  edge  of 
the  vulva.  At  this  instant  the  perinaeum  retires  backwards,  and 
passes  under  the  nape  of  the  neck,  which  revolves  above  it,  whilst 
the  occiput  turns  backwards  towards  the  anus  of  the  woman.  A« 
soon  as  the  occiput  begins  to  turn  backwards,  the  different  parts  of 
the  face,  which  until  then  had  been  retained  in  the  interior  of  the 
pelvis,  successively  disengage  themselves  from  under  the  pubis,  in 
the  order  which  has  already  been  pointed  out: 


592 

When  the  chin  appears  externally,  the  face  remains  sometimes 
stationary ;  afterwards  it  turns  towards  one  of  the  woman's  groins, 
but  only  at  the  same  instant  that  one  of  the  shoulders  presents  to- 
wards the  pubis,  and  the  other  towards  the  sacrum.  This  position, 
also,  is  one  of  those  in  which  it  is  allowable  to  be  ignorant  which 
of  the  shoulders  may  present  towards  the  pubis  ;  for  it  is  uncer- 
tain which  ;  and  when  the  change  of  position  is  procured  by  the 
aid  of  art,  it  is  indifferent  which  we  bring  there. 

These  divisions  of  the  presentations  of  the  vertex  or  crown  of 
the  head,  originated  as  we  believe,  with  the  experienced  Baude- 
locque,  and  on  this  subject  he  very  judiciously  observes,  that  the 
head  may  without  doubt  present  at  the  superior  strait,  in  a  manner 
different  from  those  described.  The  posterior  fontanelle,  which 
as  we  have  before  observed,  we  should  always  take  for  our  euide, 
may  sometimes  correspond  to  the  intermediate  spaces  between 
these  six  points ;  so  that  we  might  perhaps  distinguish  six  other 
positions,  which  might  be  again  subdivided  into  as  many  more. 
This  distinction,  he  remarks,  would  not  only  be  useless  and  super- 
fluous, but  might  confuse  the  ideas.  There  is  not  in  fact  any  of 
these  middle  positions,  which  may  not  be  referred  to  one  of  the 
six  first ;  and  each  of  them  ought,  therefore,  properly  to  be  desig- 
nated by  the  name  of  that  to  which  it  approaches  the  nearest,  as 
the  mechanism  of  delivery  in  it  is  exactly  the  same. 

These  intermediate  positions,  therefore,  ought  to  be  referred  to 
the  three  first,  as  often  as  the  posterior  fontanelle  answers  to  any 
point  of  the  anterior  semi-circumference  of  the  pelvis  ;  because 
that  fontanelle  turns  gradually  towards  the  symphysis  of  the  pubis, 
under  which  the  occiput  is  ultimately  situated. 

The  head,  continues  Baudelocque,  sometimes  follows  this  direc- 
tion, even  though  the  fontanelle  in  question,  be  placed  opposite 
one  of  the  sacro-iliac  symphyses  at  the  commencement  of  labour ; 
but  when  it  is  more  backward,  and  answers  to  some  point  in  the 
posterior  third  of  the  superior  strait,  all  those  positions  ought  to  be 
referred  to  the  three  latter,  that  is  to  say,  to  the  fourth,  fifth  or 
sixth  ;  because  the  occiput  constantly  turns  in  descending,  towards 
The  sacrum,  and  the  forehead  under  the  pubis. 


TABLE  No.  1. 


The  forepart  of  the 

Neck,  or  the  Throat, 

presenting 

to  the  (Is  Fieri. 
The  Breast 
presenting 

at  the 

Oa  Uteri. 

The  abdomen 

presenting 

lit  the 

Os  Uteri. 

Tin-  forepart  of  the 

Thighs 

and  the  Pelvis, 

m-  the  Sexual  Parts, 

presenting 

at  ilie  Os  Uteri. 

The  Rack  of  the 
Neck 


t&'tl, 

at  theOs  Uteri. 

The  Back 

presenting 
at  the 

|<2| 
1. So 

Tl 

Os  Uteri. 
e  Lumbar  Region 
presenting 
at  the 

The  Sale 
of  the 

Neck 
presenting 

at  the 
Os  Fieri. 


The  Shoulder, 
Elbow, 


One  of  the 

Sides 

of  the  Child 
presenting 

ai  the 
Os  I'teri. 


One  of  the 


I  TABEE  of  the  Various  Presentations  at  the  period  of  Parturition,  which  indispensably  require  thai  the  Chad  be  turned  mul  dvlirrml  by  the  Feet.  (According to baudelocotw 


Of  which 

there  are 

IV 

positions,  via 


Of  which 

there  are 

IV 

positions,  vie. 


1! 


of  the  Child 

presenting 

at  the 

(>  Uteri. 


■The  lower  pari  of  the  Fare  on  the  Pubes;  the  upper  part  of  the  Breast  on  the  projection  of  the  Sacrum. 
a/The  Breast  over  the  Pubes  and  the  Pace  towards  the  Sacrum.        -        -     •-        - 

The  face  on  the  anterior  part  of  the  left  Ilium,  and  the  Breast  on  the  right. Ilium,     - 

i^The  Face  on  the  anterior  part  of  the  right  Ilium,  and  the  Breast  on  the  left. 

■The  forepart  of  the  Neck  over  the  Pubes,  and  the  Abdomen  over  the  Sachroi.         -       - 

The  ion  part  of  the  Neck  over  the  base  of  the  Sacrum,  and  the  Abdomen  over  the  1  ubes. 
!  The  Neck  and  Head  resting  on  the  hit  lliirn;  and  die  Abdomen  on  the  right  Ilium. 
ii.  The  Neck  and  Head  resting  on  the  right  Ilium;  and  the  \bdomen  on  thelelt. 
t  The  Breast  above  the  Pubes;  the  inferior  Extremities  above  the  Sacrum. 
BThe  Breast  above  the  Sacnun ;  tte  inferior  Extremities  above  the  Pubes,       • 
j  The  Breast  resting  on  the  left  Blum;  the  Thighs  and  Knees  on  the  right  Blum.        - 
I  The  Breast  resting  on  the  right  Bium;  the  Thighs  and  Knees  on  the  kft<        -        -        ",'.".    ,' 
|  The  Knees  above,  or  on  one  side  of  the  projection  of  the  Sacrum!  ''"'  Abdomen  above  the  Tubes;  the; 
Breast  and  Face  to  the  anterior  portion  of  tlie  Uterus.  S 

.  The  Ko.es  over  the  anterior  brim  of  the  Pelvis:  the   Breast  and  Face  to  the  posterior  portion  of  the  ) 

I    1.  Ills. 

i  The  Knees  to  the  concavity  of  the  right  Ilium;  the  Breast  to  the  left  Ilium 

[.  The  Knees  to  the  concavity  of  the  left  Bium;  the  Breast  to  the  right  Ilium.    - 


Either  the  right  or  left  hand  or  tin-  practitioner,  indifferently,  to  be  introduced  to  turn  the  Child. 

The  right  hand  to  be  introduced  when  the  Fare  is  on  the  right  side  of  the  vertebra]  column,  and  vice  versa. 

The  left  hand  to  be  introduced  to  reach  the  Feet  and  turn  the  Child,  &c. 

The  right  hand  to  be  introduced.  &c.  &c. 

Either  the  right  or  left  baud,  indifferently,  to  be  introduced. 

The  r'mht  hand  to  be  introduced  w  hen  the  Fai  e  is  on  the  right  side  of  the  vertebral  column,  and  vice  versa. 

The  left  hand  to  be  introduced,  (fee.  &c. 

The  right  hand  to  be  introduced,  &c.  &c. 

The  right  or  left  hand  mav  lie  introduced,  indifferently,  &C. 

The  '  ight  or  left  hand,  indifferently,  mav  be  introdui  ed. 

The  left  hand  to  be  introduced  towards  the  right  side  of  the  Uterus. 
The  right  hand  to  he  introduced  towards  the  left  side  ofthe  Uterus. 


Of  which 
there  are 

IV 

positions,  vis 


Of  which 

there  are 

IV 

positions,  viz. 


1st.  The  Occiput  over  the  margin  of  the  Pnbes;  the  Back  above  the  Sacrum. 

■2d.  The  Occiput  on  one  side  of  the  projection  of  the  Sacrum;  the  Back  above  the  Pubes. 

3d.  The  Occiput  on  the  left  nium;  the  Back  to  the  right  Bium.  ....--- 

4th.  The  Occiput  to  the  right  Ilium;  the  Back  to  the  left  Bium.  ------- 

'  1st.  The  back  of  the  Neck  over  the  margin  ofthe  Pubes;  the  Lumbar  Ri  gipn  above  the  Sacrum. 

2d,  The  Lumbar  Region  over  the  Pubis;  the  back  ol  the  Neck  over  the  posterior  margin  ofthe  Pelvis.     - 

Sd.  The  Occiput  on  the  left  Bium;  the  Lumbar  Region  on  the  right  Bium. 

4th.  The  Occiput  to  the  right  Bium;  the  Lumbar  Region  on  the  left  Bium. 

"  1st.  The  Back  above  the  Pubes ;  the  Thighs  above  the  Sacrum. 

',  2d.  The  Thighs  and  Feet  above  the  Pubes;  the  Back  and  Head  towards  the  Sacrum 

3d.  The  Back  on  the  left  Ilium :  the  Thighs  and  Feet  on  the  right  Ilium. 

4th.  The  Back  on  the  right  Ilium;  the  Thighs  and  Feel  on  the  left  Ilium. 

1st.  The  Ear  and  angle  of  the  Lower  Jaw  to  the  Pubes;  the  Shoulder  towards  the  Sacrum.  The  Face  towards  j 

the  left  side  ofthe  mother  when  the  right  side  ofthe  Neck  presents,  and  vice  versa.  < 

2d.  The  Ear  and  angle  "I  the  lower  Jaw  toward-  the  Sacrum;  the  Shoulder  towards  the  Pubes.     The  Face  ] 

towards  the  right  side  ofthe  mother  when  die  right  side  ofthe  Neck  presents,  and  vice  versa. 
3d.  The  side  ,,f  the  Mead  upon  the  left  Ilium,  and  the  Shoulder  on  the  right  Ilium.     The  Face  towards  the  ] 

Si i  when  the  right  side  of  the  Neck  presents  ;  towards  the  Pubes  when  the  left.  I 

4tli.  The  side  of  the  Head  upon  the  right  Ilium,  and  the  Shoulder  on  the  left  Ilium.     The  Face  towards  the  , 

Pubes  when  the  right  side  Ofthe  Neck  proems ;  towards  the  Sacrum  when  the  left. 
]  si.   The  side  ofthe  Are/,  on  the  Pubes,  and  the  Side  over  the  Sacrum.      The  Breast  towards  the  left   Ilii 

n  Ben  the  right  Shoulder  or  \rm  presents;  and  towards  the  right  Ilium  when  the  left  Shoulder  or  Arm  ] 

prt  sents, 
2d    The  side  ofthe  Neck  over  the  Sacrum,  and  the  Sub  over  the  Pubes.    The  breast  towards  the  right  Ilium  , 

when  the  right  shoulder  presents,  and  vice  versa. 
3d   The  Neck  and  Head  on  the  left  Ilium  ;  the  Side  and  Hip  on  the  right  Ilium.     The  back  to  the  forepart  , 

ofthe  Uterus  when  the  right  Shoulder  prBSI  nts,  anil  to  the  back  pari  when  the  left  presents. 
4ih.  The  Neck  and  11.  ad  on  the  right  Ilium  ;  the  Side  and  Hip  on  the  left  Ilium.     The  breast  to  the  forepart  i 

ofthe  Uterus  when  the  right  Shouldei  and   \rm  psesents,  and  vice  versa.  ' 

I  s|.  The  Axilla  over  the  Pubes ;  the  Hip  over  the  Sacrum.    The  Breast  towards  the  left  Bium  when  the  right  i 

Side  presents,  ami  vice  versa. 
2d.  The  Axilla  over  the  Sacrum  :  the  Hip  over  the  Pubes.  The  Breast  towards  the  right  Ilium  when  the  right 

Sid.   presents,  and  vice  \.  i-.i.  ] 

:;.|.  The  \xilla  on  the  left  Ilium  :  the  Hip  on  the  right  Ilium.  The  Breast  towards  the  back  part  of  the  Uterus  , 

when  the  right  Side  presents,  and  vice  versa.  J 

4th.  The  Axilla  on  the  right  Ilium;  the  Hip  on  the  left  Ilium.  The  Breast  towards  the  fore  part  of  the  Uterus  ] 

when  the  right  Side  presents,  and  vice  versa,  ' 

1st.  The  Thighs  towards  the  Sacrum;  the  Spine  of  the  Ilium  towards  the  Pubes.     The  Breast  towards  the  i 

hit  side  of  the  Uterus  when  the  right  Hip  presents,  and  vice  versa.  < 

24.  The  Thighs  towards  the  Pubes;  the  Spine  of  the  Ilium  towards  the  Sacrum.     The  Breast  towards  the  i 

side  oi  die  Uterus  when  the  r'urht  Hip  presents,  and  vice  versa.  t 

3d.  The  Thighs  towards  the  ii;:lit  side;  the  Spine  of  the  Ilium  towards  the  left  side.    The  Breast  towards  the  { 

posterior  part  of  the  Uterus  when  the  right  Hip  presents,  and  vi<  ■  I 

4th.  The  Thighs  towards  the  left  side;  the  Spine  of  the  Ilium  towards  the  right  side.   The  Breast  towards  the  i 

anterior  part  of  the  Uterus  when  the  right  Hip  presents,  and  vice  Versa.  i 


The  right  or  left  hand,  indifferently,  may  be  introduced. 

The  right  or  left  hand,  Indifferently,  may  be  introduced. 

-  The  left  hand  lo  l.e  inii  odn.  id  towards  the  right  si.lp  ofthe  Uterus. 
•     The  right  hand  to  be  introduced  towards  the  left  side  ofthe  Uterus. 

-  Either  the  right  or  left  hand,  indifferently,  to  be  introduced,  &c. 
Either  tin-  right  or  left  hand,  indifferently,  to  be  introduced. 

.  The  right  band  to  be  introduced  towards  the  left  side  ofthe  Uterus. 

-  Tin'  left  hand  to  be  introduced  towards  the  right  side  ofthe  Uterus. 

-  The  right  hand  to  be  introduced  towards  the  left  side  ofthe  Uterus. 

-  The  i  .'In  band, &c &c. 

-  The  right  or  left  hand,  indifferently,  &c.  &c. 

-  li"  right  or  left  hand,  indifferently,  &c. 

-  The  right  hand  to  be  introduced,  &c.  • 

-  The  right  hand,  &c. 

.     The  left  hand  to  be  introduced  towards  the  right  Ilium. 

-  The  right  hand  to  be  introduced  towards  the  left  Ilium. 

The  l  ight  hand  to  be  introduced  when  the  right  side  of  the  Neck  presents ;  the  left  hand  when  the  left  side,  &c 

The  left  hand  to  be  introduced  when  the  right  side  of  the  Neck  presents ;  the  right  hand  when  the  left  side. 

The  right  hand  to  be  introduced  when  the  right  side  of  the  Neck  presents,  &c. 

The  left  hand  to  be  introduced,  &c. 

The  right  hand  to  be  introduced  when  the  right  Shoulder;  the  left  when  the  left  Shoulder  presents. 

The  left  hand  to  be  introduced  when  the  right  Shoulder  presents;  the  right  hand  when  the  left  Shoulder,  &c. 

The  right  hand  to  be  introduced  when  the  right  Shoulder  presents;  the  left  hand  when  the  left  Shoulder,  &c. 

The  right  hand  to  be  introduced  when  the  right  Shoulder  presents ;  the  left  hand  when  the  left  Shoulder,  &c 

The  right  hand  to  be  introduced  if  the  right  Side  presents;  the  left  hand  if  the  left  Side  presents. 

The  left  hand  to  be  introduced  if  the  right  Side  presents;  the  right  hand  if  the  left  Side  presents. 

The  right  hand  to  he  introduced  if  the  right  Side  presents;  the  left  hand  if  the  left  Side  presents* 

The  right  hand— if  right  Side— the  left  hand  if  left  Side. 

The  right  hand  to  be  introduced  when  the  right  Hip  presents:  the  left  hand  when  the  left  Hip,  &c.. 

The  left  hand  to  be  introduced  when  the  right  Hip  presents;  the  right  hand  when  the  left  Hip,  &c. 

The  left  hand  to  be  introduced  in  both  varieties  of  the  position. 

The  right  hand  to  be  introduced  in  both  varieties  ofthe  position. 


't£^£££tt2*2£^  S3  ££R5R£2^  or  u,e  'pptotion  of  u,c  rMCe>" becomes  neccss^  "te  *■ Woman  ,n  a  Supine  I'oslt,on- wilh  lbe  Brcec" broUBht  lo  thc  edce  °r  M  of  ,h£  bc0- s9  *-  *■ 


referred  to  ine  tnree  laiter,  umi  is  iu  say,  t«  *..„  v.  , 

sixth  ;  because  the  occiput  constantly  turns  in  descending,  towards 
the  sacrum,  and  the  forehead  under  the  pubis. 


No.  2. 
TABLE  OF  CASES  OF  LABOUR, 

Which  occurred  at  VHoapice  de  hi  Maternitc  in  Paris,  from  the  10th  December,  1797,  to  the  3Ut  July,  180G,  inclusively. 

Women  delivered 12,605.  Infants  born -    -    12,751. 

8ne  hundred  and  forty-two  of  these  women  had  twins.     Two  only  had  triplets. 

'  If  these  12,751  infants,  one  hundred  and  eighteen  were  born  before  the  admission  of  their  mothers  into  the  Hospital,  or  with  such  haste,  that  there  was  no 
lime  to  ascertain  the  part  which  presented,  or  the  real  position. 

Many  of  this  number  were  not  beyond  the  term  of  four  or  five  months,  and  some  from  five  to  six,  which  reduces  the  number  to  12,633,  of  those  in  whom 
could  be  accurately  ascertained  the  part  which  presented  to  the  orifice  of  the  uterus,  in  the  course  of  the  labour  and  delivery,  and  the  position  of  the  particular 
part. 

'/'/«•  Regions  which  Presented,  the  number  of  Times,  and  tlteir  Position?, 


Number  of 
times. 

First 
Position. 

Second 
Position. 

Third 
Position. 

Fourth 
Position. 

Fifth 
Position. 

Sixth 
Position. 

Positions  not 
ascertained. 

The  crown  of  the  head  or  vertex 

12,183 

10,003 

2,113 

4 

40 

22 

1 

But  four  Positions  of  all  the  other  Regions  are  admitted  to  exist. 

The  Breech  or  the  thighs 

The  feet 

The  knees      ..... 
The  face        - 

The  belly 

The  occipital  region      - 

The  hack        ..... 

The  loins 

The  right  side  of  the  head     - 
The  left  side  of  the  head 
The  nght  shoulder 
The  left  shoulder 
The  right  side  of  the  thorax  - 
The  left  side          .... 
The  right  hip         .... 
The  left  hip            .... 

-  198 

-  147 

42       .* 
3       - 
1 

1 

4 
20 
18 

2  . 
1 

3  - 
1 

118 
85 
1 
1 
1 
1 
1 
1 
0 
2 
0 
1 
0 
0 

1 

0 

71 

58      - 
0       - 
0       - 
0      . 
0      . 

0  . 

1  . 
0      . 
0       . 
0      - 
O       - 
0 

0       - 
0       - 
0       - 

3 

1 

22      . 

1  - 
0       . 

2  . 
0      . 

0  - 

1  . 
7      - 
9      - 
0      - 

0  - 

1  - 
1 

6      - 
1       - 
0       - 
17      - 
0       - 
0       - 
0       - 
0      - 

0  - 
1 

13       - 
8      - 

1  . 
1 

0       - 
0       - 

: 

12,633 

213 

130 

51 

48 

8 

No.  3. 


COMPARATIVE  STATEMENT 

Of  the  Labours  winch  were  accomplished  by  Nature  alone,  with  those  in  which  the  aid  of  Art  was  necessary. 

Of  twclre  thousand  seven  hundred  and  Jifty-one  cases  of  Labour,  12,573  at  least  were  accomplished  naturally,  and  but  one  hundred  and  seventy-eight,  at 
Jnnst,  require^  the  Assistance  of  art ;  some  by  means  of  the  hand  alone,  others  with  the  forceps,  or  with  the  crotchet,  after  the  perforation  of  the  Cranium,  which 
is  in  the  proportion  of  I  to  71  '2-3. 

<  feses  in  which  ii  beca necessary  to  give  assistance  In  die  head  alone,  either  because  of  the  unfavourable  situation  of  the  child,  or  on  account  of  the  mal- 

ronformation  of  the  pelvis,  or  from  accidental  circumstance,  which  render  the  labour  complex. 
Our  hundred  <unl  thirty-two  in  all — which,  in  proportion  to  the  whole,  is  as  1  to  96  3-5. 
\  a  :  The  child  presenting 

The  face IS 

The  shoulders    - 38 

The  crown  of  the  head  with  the  umbilical  cord IT) 

The  breech         ----..-.-...         22 

The  feel  ....-11 

The  other  parts  specified  in  the  table  ......         24 

On  account  of  conviKinns  and  floodings        ......  4 


The  forceps  were  applied  in  thirty-seven  cases,  which  h  as  l  to  344  2-3. 
The  child  presenting  the  face 
The  crown  of  the  head 


Total 


132 


Ol  these  latter  the  forceps  were  applied. 


(  In  ten  on  account  of  the  exit  of  the  cord;  ten  on  account  of  the  exhaustion  of  the  woman's  strength, 
j      six 


six  on  account  of  convulsions. 

seven*  account  of  the  unfavourable  situation  of  the  head,  which  had  been  thrown  backwards,  &c. 
[      two  onarcount  of  the  mal-conformation  of  pelvis. 
I  lie  crotchet  was  employed,  or  the  cranium  perforated  in  niiu — which  is  in  the  proportion  of  1  to  1,416  2-3  : 
\  iz :   )  on  account  of  hydrocephalus  in  the  child. 

8  on  account  of  great  deformity  rathe  pelvis. 
One  by  gastrotomy  to  extract  an  extra-uterine  fetus. 
Remark, — Ol  42  children  inyvhom  the  face  presented,  iC  were  bom  without  any  assistance,  6  were  brought  to  one  of  the  positions  of  the  vertex,  after  which 

thej   were  delivered  without  assistance. 
( >i  ]  08 — where  the  breech  or  thighs  presented,  176  were  born  without  extra  aid. 
( )l  J. 17 — where  the  feet  presented.  136  were  bom  in  the  same  way. 
<>l  [4,751,  the  cord  first  came  out  but  36  times,  viz:  35  times  when  the  vertex  presented,  and  only  once  with  the  feet. 

Sex  of  the  Children. 
Children  born  12,751.  6,524  Boys.  6,227  Girls. 

Children  dead  530;  \iz:  before  the  period  of  labour  412  ;  during  labour,  or  shortly  after  birth,  118. 
I  he  relative  proportion  of  children  still-born,  and  oftln.se  who  survived  but  a  few  moments  after  birth,  to  15,751,  is  as  1  to  24  1-2. 

Weight  of  the  Children. 

7,077  were  weighed  with  the  greatest  accuracy  ;  and  of  this  number, 


34  weighed   from    I  lb.  to   1  1-2  lb. 

69  from  2  lb.  to  2  3-4   lb. 

164  from  3  lb.  to  3  3-4  lb. 

396  from  4  lb.  to  4  3-4  lb. 

1,317  from  5  lb.  to  5  3-4  lb. 


2,799  weighed  from  6  lb.  to  6  3-4  11). 

1,750  from  7  lb.  to  7  3-4  lb. 

463  from  8  lb.  to  8  3-4  lb. 

82  from  9  lb.  to  9  1-2  lb. 

10  lb. 


It  would  appear,  from  the  result  of  the  experience  of  the  superintendents  of  the  Hospital,  from  which  the  above  table  has  been  taken,  that  preternatural  and 
difficult  cases  occur  more  frequently  in  certain  years,  than  in  others. 


Date  Due 

L.  B.  Cat.   No.  1137 

618.2      B967          v.l      42503 
Bu  rne 

Principles  of  Midwifery 

DATE  DUE 

ISSUED  TO 

1 

618.2     B967  v.l  43503 


>m 


